THE  LIBRARY 

OF 

THE  UNIVERSITY 
OF  CALIFORNIA 


PRESENTED  BY 

PROF.  CHARLES  A.  KOFOID  AND 
MRS.  PRUDENCE  W.  KOFOID 


TREASURY   DEPARTMENT. 
Public  Health  and  Marine-Hospital  Service  of  the  United  States. 

WALTER  WYMAN,  Surgeon-General. 


HYGIENIC  LABORATORY.— BULLETIN  No.  10. 

XJ     J.   WOSENAU,  Director. 
^ebruary,  19O3. 


REPORT 

UPON   THE 

PREVALENCE  AND  GEOGRAPHIC"  DISTRIBUTION  OF  HOOKWORM  DISEASE 

{Uncinariasis  or  Anchylostomiasis} 


IN    THE 


UNITED   STATES. 


BY 


CH.  WARDELL   STILES,  Ph.  D. 
Chief  of  Division  of  Zoology. 


WASHINGTON: 

GOVERNMENT    PRINTING    OFFICE. 
1903. 


NOTICE    TO    LIBRARIANS    AND    BIBLIOGRAPHERS,    CONCERNING    THE 
SERIAL  PUBLICATIONS  OF  THIS  SERVICE. 

The  Hygienic  Laboratory  was  established  in  New  York,  at  the  Marine  Hospital 
on  Staten  Island,  August,  1887.  It  was  transferred  to  Washington,  with  quarters  in 
the  Butler  Building.  June  11,  1891,  and  a  new  laboratory  building,  to  be  located  in 
Washington,  was  authorized  by  act  of  Congress,  March  3,  1901. 

The  following  bulletins  (Bull.  Nos.  1-7,  1900  to  1902,  Hyg.  Lab.,  U.  S.  Mar.-Hosp. 
Serv.,  Wash.)  have  been  issued: 

No.  1.  Preliminary  notes  on  the  viability  of  the  Bacillus  pestis.  By  M.  J. 
Rosenau. 

No.  2.  Formalin  disinfection  of  baggage  without  apparatus.     By  M.  J.  Rosenau. 

No.  3.  Sulphur  dioxide  as  a  germicidal  agent.     By  H.  D.  Geddirigs. 

No.  4.  Viability  of  the  Bacillus  pestis.     By  M.  J.  Rosenau. 

No.  5.  An  investigation  of  a  pathogenic  microbe  (B.  typhi  murium  Danyz)  applied 
to  the  destruction  of  rats.  By  M.  J.  Rosenau. 

No.  6.  Disinfection  against  mosquitoes  with  formaldehyd  arid  sulphur  dioxide. 
By  M.  J.  Rosenau. 

No.  7.  Laboratory  technique:  Ring  test  for  indol,  by  S.  B.  Grubbs  &  Edward 
Francis;  Collodium  sacs,  by  S.  B.  Grubbs  &  Edward  Francis;  Microphotographj 
with  simple  apparatus,  by  H.  B.  Parker. 

By  act  of  Congress,  approved  July  1, 1902,  the  name  of  the  "United  States  Marine- 
Hospital  Service"  was  changed  to  the  "'Public  Health  and  Marine-Hospital  Service 
of  the  United  States,"  and  three  new  divisions  were  added  to  the  Hygienic  Labora- 
tory. 

Since  the  change  of  name  of  the  service  the  bulletins  of  the  Hygienic  Laboratory 
have  been  continued  in  the  same  numerical  order,  as  follows: 

No.  8. — Laboratory  course  in  pathology  and  bacteriology.     By  M.  J.  Rosenau. 

No.  9. — Presence  of  tetanus  in  commercial  gelatin.     By  John  F.  Anderson. 

No.  10. — Report  upon  the  prevalence  and  geographic  distribution  of  hookworm 
disease  (uncinariasis  or  anchylostomiasis)  in  the  United  States.  By  Ch.  Ward  ell 
Stiles. 

In  citing  these  bulletins,  beginning  with  No.  8,  bibliographers  and  authors  are 
requested  to  adopt  the  following  abbreviations:  Bull.  — ,  Hyg.  Lab.,  U.  S.  Pub. 
Health  &  Mar.-Hosp.  Serv.,  Wash.,  pp. . 

MAILING   LIST. 

The  laboratory  will  enter  into  exchange  of  publications  with  medical  and  scientific 
organizations,  societies,  laboratories,  journals,  and  authors.  Its  publications  will  also 
be  sent  to  nonpublishing  societies  and  individuals  in  case  sufficient  reason  can  be 
shown  why  such  societies  or  individuals  should  receive  them.  All  applications  for 
these  publications  should  be  addressed  to  the  "Surgeon  General,  U.  S.  Public 
Health  and  Marine-Hospital  Service,  Washington,  D.  C." 


TREASURY   DEPARTMENT. 
Public  Health  and  Marine-Hospital  Service  of  the  United  States. 

WALTER  WYMAN,  Surgeon-General. 


HYGIENIC  LABORATORY.— BULLETIN  No.  10. 

M.  J.   ROSENA1LJ,  Director. 

February,  19O3. 


REPORT 

UPON    THE 

'REVALENCE  AND  GEOGRAPHIC  DISTRIBUTION  OF  HOOKWORM  DISEASE 

{Uncinariasis  or  Anchylostomiasis) 

IN    THE 

UNITED    STATES. 


BY 


CH.  WARDELL   STILES,  Ph.  D. 
Chief  of  Division  of  Zoology. 


WASHINGTON: 

GOVERNMENT     PRINTING     OFFICE. 
1903. 


ORGANIZATION  OF  HYGIENIC  LABORATORY. 

WALTER  WYMAN,  Surgeon- General, 
U.  S.  Public  Health  and  Marine-Hospital  Service. 

ADVISORY    BOARD. 

— ,  U.  S.  Army;  Surgeon  John  F.  Urie,  U.  S.  Navy;  D.  E.  Salmon,  Chief 
of  U.  S.  Bureau  of  Animal  Industry;  and  Milton  J.  Rosenau,  U.  S.  Public  Health  and 
Marine-Hospital  Service,  ex  officio. 

Prof.  William  H.  Welch,  Prof.  Simon  Flexner,  Prof.  Victor  C.  Vaughan,  Prof. 
William  T.  Sedgwick,  and  Prof.  Frank  F.  Wesbrook. 

LABORATORY    CORPS. 

Director. — P.  A.  Surg.  Milton  J.  Rosenau. 
Assistant  Director. — Asst.  Surg.  John  F.  Anderson. 
Pharmacist.— M.  H.  Watters,  Ph.  G. 

DIVISION   OF   PATHOLOGY    AND    BACTERIOLOGY. 

Chief  of  Division. — P.  A.  Surg.  Milton  J.  Rosenau. 

Assistants.— Asst.  Surgs.  John  F.  Anderson,  Herman  B.  Parker,  Edward  Francis 
Thomas  B.  McClintic,  and  Clarence  W.  Wille. 

DIVISION   OF  ZOOLOGY. 

Chief  of  Division.— Oh.  Wardell  Stiles,  Ph.  D. 

Assistants. — Phillip  E.  Garrison,  A.  B.;  Brayton  H.  Ransom,  B.  Sc.,  M.  A.;  Earle 
C-  Stevenson,  B.  Sc. ;  Arthur  L,  Murray. 
2 


CONTENTS. 


Page. 

Summary 9 

Introduction 11 

Definition 11 

Terminology •  11 

Historical  review 12 

Brief  review  of  hookworms 12 

Zoological  position  of  the  parasites 13 

Family  Strongylidse 13 

Subfamily  Strongylinae 14 

Genus  Undnaria  Froelich,  1789 15 

[  Undnaria  Froelich,  1789,  sensu  stricto] 19 

The  New  World  hookworm —  Undnaria  americana  Stiles,  1902 — 

of  man 19 

Life  history  of  Undnaria  americana 20 

Development  outside  the  body 20 

Development  inside  the  body 20 

[Agchylostoma  Dubini,  1843] 21 

The  Old.  World  hookworm — Agchylostoma  duodenale   Dubini, 
1843,  or  Undnaria  duodenalis( Dubini,  1843)  Kailliet,  1885— 

of  man _> 21 

Life  history  of  Agchylostoma  duodenale 24 

Development  outside  the  body 25 

Segmentation 25 

Embryo 25 

Second  stage 26 

Development  inside  the  body 28 

Third  stage  (without  buccal  capsule) 28 

Fourth  stage  (with  provisional  buccal  capsule) 28 

Fifth  stage  (with  definite  buccal  capsule) 30 

Source  of  infection- of  uncinariasis 30 

Brief  review  of  uncinariasis 31 

Brief  review  of  uncinariasis  in  the  United  States 32 

Itinerary  of  the  trip  through  the  Southern  Atlantic  States 37 

District  of  Columbia 37 

Virginia 37 

Richmond  and  State  Farm 37 

North  Carolina 38 

Virgilina  copper  mine  district,  southern  Virginia  and  northern  North 

Carolina 38 

Cumnock  coal  mines,  Chatham  County 38 

Sanford,  Moore  County 38 


Itinerary  of  the  trip  through  the  Southern  Atlantic  States — Continued.  Page. 

South  Carolina 39 

Camden,  Camden  County 39 

Haile  Goldmine,  Lancaster  County 39 

Kershaw  County 40 

Charleston,  Charleston  County 40 

( Georgia .- 41 

Atlanta,  Fulton  County 41 

Macon,  Bibb  County : 41 

Milledgeville,  Baldwin  County 42 

Fort  Valley,  Houston  County 42 

Albany,  Dougherty  County - 43 

Willacoochee,  Coffee  County 43 

Waycross,  Ware  County 44 

Florida 44 

Jacksonville,  Duval  County 

Waldo,  Alachua  County 

Ocala,  Marion  County 

Symptomatology  of  uncinariasis 

Light  cases 

Medium  cases 

Severe  cases 

General  predisposing  factors 

Infection  occurs  chiefly  on  sandy  soil 

Infection  occurs  chiefly  in  rural  districts 

Symptoms  are  more  severe  in  summer  than  in  winter 

Whites  appear  to  be  more  severely  affected  than  negroes 

Occupation  of  patients , 

Severe  cases  are  more  common  in  women  and  children  than  in  males  over 

25  years  of  age 

Several  cases  are  likely  to  occur  in  the  same  family 

Objective  and  subjective  symptoms;  analysis  of  symptoms.  _*. 

Onset  and  incubation . 

Stages  of  uncinariasis 

Stage  of  purely  local  symptoms 

Stage  of  simple  anemia  or  oligocythemia  (chlorotic  stage) 

Dropsical  ^tage 

Duration  of  uncinariasis 

Length  of  life  of  the  individual  parasites 

General  external  appearance 

General  lack  of  development;  stunted  growth.  _fc_ 

Skin 

Wounds  heal  slowly 

Cutaneous  lesions  caused  by  uncinariasis 

Looss's  theory  of  cutaneous  infection 

Bentley's  theory  of  ground  itch 

Hair 

Breasts 

Nails 

Head 

Face .' 

Eyelids,  conjunctive , 

Eyes , 


Objective  and  subjective  symptoms;  analysis  of  symptoms — Continued.  Page. 
General  external  appearance — Continued. 
Head — Continued. 

Nostrils ,., 66 

Lips  and  gums 66 

Teeth '. 66 

Tongue 67 

Neck 67 

Thorax 67 

Abdomen 67 

' '  Potbelly  "  or  "  buttermilk  belly, ' '  dropsy  and  tympanites 67 

Extremities. 68 

Genitalia  . ' 68 

Mucous  membranes 68 

Excretions  and  secretions 68 

Urine 68 

Feces 68 

Consistency 68 

Eeaction 68 

Color ' 68 

Blotting  paper  test 69 

Microscopic  examination 69 

Circulatory  system 69 

Anemia 69 

Blood 70 

Cervical  pulsations 72 

Heart 72 

Pulse 72 

Temperature 72 

Respiratory  system 72 

Nostrils „ 72 

Respiration .*. 72 

Muscular  system 73 

Emaciation 73 

Great  physical  weakness 73 

Digestive  system 74 

Lips,  gums,  teeth,  tongue  (see  p.  66) 74 

Nausea 74 

Appetite 74 

Perverted  appetite,  ' '  dirt-eating  " 74 

Pain  in  "  stomach; "  indigestion 76 

Constipation  and  diarrhea 77 

Feces 77 

Nervous  system 77 

Eyes 77 

Ears 77 

Mental  lassitude,  headache,  dizziness,  arid  nervousness 77 

Patellar  reflex t  78 

Genital  system 78 

External  genitalia,  sexual  function,  menstruation,  sterility. . 78 

Tendency  to  abortion 79 

Prevalence  of  uncinariasis  in  the  United  States  . .  79 


6 

Objective  and  subjective  symptoms;  analysis  of  symptoms — Continued.  Page. 

Clinical  diagnosis  of  hookworm  disease 80 

Blotting  paper  test  with  feces 81 

Microscopic  examination  of  feces 85 

Gross  examination  of  feces 86 

Treatment  of  hookworm  disease 86 

Anthelminthic  treatment 86 

Thymol 86 

Male  fern 89 

Calomel 89 

General  treatment 89 

Prognosis 89 

Lethality  of  hookworm  disease 90 

Post-mortem  appearances 91 

Prevention  of  hookworm  disease 93 

Adult  worms  in  the  intestine;  treatment 93 

Eggs  in  the  feces;  control  and  destruction 93 

The  infecting  (encysted)  stage  of  the  larva 94 

Disinfecting  premises 94 

Drinking  water 95 

Clean  hands 95 

Wearing  shoes 95 

Common  interpretation  of  hookworm  disease 96 

Economic  importance  of  hookworm  disease 96 

Geographic  distribution  and  abstracts  of  cases  found  in  the  United  States 98 

Bibliography Ill 

Index  to  zoological  names 117 

Index  to  authorities  cited..  119 


LIST  OF  ILLUSTRATIONS. 


Page. 
FIG.  1.  Caudal  bursa  of  a  male  strongyle  ((Esophagostoma  dentatum]  to  serve 

as  diagram  for  the  family 13 

2-9.  New  World  hookworm  (  Uncinaria  americana) . 

2.  New  World  male  hookworm 18 

3.  New  World  female  hookworm 18 

4.  The  same  enlarged  to  show  the  position  of  the  anus  and  vulva 18 

5.  Dorsal  view  of  anterior  end  of  New  World  hookworm 18 

6.  Lateral  view  of  anterior  end  of  New  World  hookworm 18 

7.  Lateral  view  of  caudal  bursa  of  New  World  male  hookworm 18 

8.  Caudal  end  of  New  World  male  hookworm 19 

9.  Four  eggs  of  New  World  hookworm 20 

10-41.  Old  World  hookworm  (Agchylostoma  duodenale). 

10.  Dorsal  view  of  anterior  end  of  Old  World  hookworm 22 

11.  Old  World  male  hookworm 22 

12.  Old  World  female  hookworm 22 

13.  The  same  (diagrammatic)  enlarged  to  show  the  position  of  the  anus 

and  vulva 22 

14.  Semidiagrammatic  figure  of  caudal  bursa  of  same 22 

15.  Lateral  view  of  Old  World  male  hookworm  enlarged  to  show  the 

anatomy 23 

16.  Eggs  of  Old  World  hookworm 24 

17-29.  Embryology  of  Old  World  hookworm. 24 

30-31.  Larvse  at  the  end  of  the  second  stage  (encysted  larvae) 25 

32.  A  young  hookworm  of  man,  without  buccal  capsule,  four  days  after 

infection 26 

33.  Anterior  end  of  larval  hookworm  during  formation  of  provisional 

buccal  capsule 26 

34.  Head  of  larval  hookworm  before  entering  the  fourth  stage,  five  davs 

after  infection 26 

35.  Young  hookworm  in  fourth  stage,  with  provisional  buccal  capsule 27 

36.  Provisional  buccal  capsule  (fourth  stage)  of  larval  hookworm,  about 

nine  days  after  infection 27 

37.  Young  male  hookworm,  about  nine  days  after  infection 27 

38-39.  Development  of  definite  buccal  capsule 28 

40-41.  Male  and  female  hookworms  before  the  fourth  casting  of  skin,  fourteen 

to  fifteen  days  after  infection 29 

42.  A  severe  case  of  hookworm  disease  observed  in  Florida 46 

43-85.  Eggs  and  embryos  of  other  parasitic  worms. 

43.  Egg  of  common  eel  worm  or  ascaris  (Ascaris  lumbricoides)  of  man 82 

44.  The  same,  optical  section,  seen  with  median  focus 82 

45-54.  Embryology  of  common  ascaris  of  man  after  the  egg  is  discharged  in 

the  feces 82 

55.  Embryo  of  the  common  ascaris  of  man,  in  its  eggshell 82 


8 

Page. 

FIG.  56.  Free  embryo  of  common  ascaris  of  man,  casting  its  skin 82 

57-64.  Embryology  of  the  common  pin  worm  (Oxyuris  vermicularis]  of  man, 

while  egg  is  still  in  the  female  worm 82 

65.  Embryo  of  the  common  pinworm  of  man,  in  the  eggshell,  as  found  in 

the  fresh  feces 82 

66.  Full-grown  embryo  of  the  common  pinworm  of  man,  escaped  from  its 

shell 82 

67-70.  Egg  of  common  whipworm  (Trichuris  trichiura)  of  man,  showing 
changes  undergone  while  still  in  the  female  worm;  fig.  69  is  the  stage 

found  in  fresh  feces 82 

71-73.  Later  stages  of  development  of  an  allied  whipworm  (Trichuris  affinis) 
of  sheep  and  cattle,  showing  changes  after  the  egg  escapes  in  the 
feces 82 

74.  Isolated  embryo  of  Trichuris  affinis 82 

75.  Egg  of  Cochin-China  diarrhea  worm  (Strongyloides  stercoralis) 83 

76.  Rhabditiform  embryo  of  same 83 

77.  Filariform  larva  of  same 83 

78.  Egg  of  common  liver  fluke  (Fasciola  hepatica)  examined  shortly  after  it 

was  taken  from  the  liver  of  a  sheep.     This  is  the  same  stage  found 

in  human  feces 84 

79.  Egg  of  common  liver  fluke  containing  a  ciliated  embryo  (miracidium) 

ready  to  hatch , 84 

80.  Embryo  of  the  common  liver  fluke  boring  into  a  snail 84 

81.  Egg  of  lancet  fluke  (Dicroccelium  lanceatum)  with  contained  embryo..  84 

82.  Egg  of  human-blood  fluke  (Schistosoma  hsematobium)  with  contained 

embryo,  passed  in  the  urine  or  in  the  feces 84 

83.  Egg  of  beef-measle  tapeworm  (Tsenia  saginata),  with  thick  eggshell 

(embryophore),  containing  the  six-hooked  embryo  (onchosphere) . .         84 

84.  Eggs  of  pork-measle  tapeworm    (Tsenia  solium):  a,    with  primitive 

vitelline  membrane;  b,  without  primitive  vitelline  membrane 84 

85.  Egg  of  the  dwarf  tapeworm  (Hymenolepis  nana)  of  man 85 

86.  Spraying  with  burning  oil , 94 


SUMMARY 

Convinced  from  theoretical  deductions  that  hookworm  disease  (uncinariasis)  must 
be  more  or  less  common  in  the  South,  a  trip  was  made  from  Washington,  D.  C.,  to 
Ocala,  Fla.,  stopping  at  penitentiaries,  mines,  farms,  asylums,  schools,  and  factories, 
and  the  fact  was  established  that  the  chief  anemia  of  the  Southern  rural  sand  dis- 
tricts is  due  to  uncinariasis,  while  clay  districts  and  cities  are  not  favorable  to  the 
development  of  this  disease. 

In  the  Old  World,  hookworm  disease  was  probably  known  to  the  Egyptians  nearly 
three  thousand  five  hundred  years  ago,  but  its  cause  was  not  understood  until  about 
the  middle  of  the  nineteenth  century,  when  it  was  shown  to  be  due  to  an  intestinal 
parasite,  Agchylostoma  duodenale.  Until  1893  no  authentic  cases  of  this  disease  were 
recognized  as  such  in  the  United  States,  but  between  1893  and  1902  about  35  cases 
were  diagnosed.  In  1902  it  was  shown  that  a  distinct  hookworm,  Uncinaria  ameri- 
cana,  infests  man  in  this  country,  and  this  indicated  very  strongly  that  the  disease 
must  be  present  although  not  generally  recognized.  It  is  now  established  that  in 
addition  to  the  few  cases  of  Old  World  hookworm  disease  imported  into  the  United 
States  we  have  in  the  South  an  endemic  uncinariasis  due  to  a  distinct  cause,  Uncina- 
ria americana.  This  disease  has  been  known  for  years  in  the  South  and  can  be  traced 
in  medical  writings  as  far  back  as  1808,  but  its  nature  was  not  understood.  Some 
cases  have  been  confused  with  malaria,  others  have  been  attributed  to  dirt-eating. 

The  hookworms  are  about  half  an  inch  long.  They  live  in  the  small  intestine, 
where  they  suck  blood,  produce  minute  hemorrhages,  and  in  all  probability  also 
produce  a  substance  which  acts  as  a  poison.  They  lay  eggs  which  can  not  develop 
to  maturity  in  the  intestine.  These  ova  escape  with  the  feces  and  hatch  in  about 
twenty-four  hours;  the  young  worm  sheds  its  skin  twice  and  then  is  ready  to  infect 
man.  Infection  takes  place  through  the  mouth,  either  by  the  hands  soiled  with 
larva?  or  by  infected  food.  Infection  through  the  drinking  water  may  possibly 
occur.  Finally,  the  larvse  may  enter  the  body  through  the  skin  and  eventually 
reach  the  small  intestine. 

Patients  may  be  divided  into  light  cases,  in  which  the  symptoms  are  very  obscure; 
medium  cases,  in  which  the  anemia  is  more  or  less  marked,  and  severe  cases,  repre- 
sented by  the  dwarfed,  edematous,  anemic  dirt-eater.  Infection  occurs  chiefly  in 
rural  sand  districts.  Above  the  frost  line  the  symptoms  are  more  severe  in  summer 
than  in  winter,  and  whites  appear  to  be  more  severely  affected  than  negroes.  Per- 
sons who  come  in  contact  with  damp  earth  are  more  commonly  infected  than  others, 
so  that  the  disease  is  found  chiefly  among  farmers,  miners,  and  brickmakers.  Severe 
cases  are  more  common  in  women  and  children  than  in  men  over  25  years  of  age. 
Uncinariasis  is  a  disease  which  occurs  in  groups  of  cases,  and  if  one  case  is  found  in 
a  family  the  chances  are  that  other  members  of  the  same  family  are  infected. 

The  testimony  of  patients  severely  infected  is  unreliable.  Recalling  that  any  one 
or  more  symptoms  may  be  absent  or  subject  to  variation,  it  may  be  noted  that  the 
period  of  incubation  (at  least  before  the  malady  can  be  diagnosed  by  finding  the 
eggs)  is  from  four  to  ten  weeks.  Stages  are  not  necessarily  distinctly  defined,  but  are 
described  as  (1)  stage  of  purely  local  symptoms,  corresponding  to  the  light  cases; 
(2)  stage  of  simple  anemia,  corresponding  to  the  medium  cases;  and  (3)  dropsical 
stage,  corresponding  more  or  less  to  the  severe  cases.  The  duration  of  the  disease 
after  isolation  from  the  source  of  infection  has  been  traced  for  six  years  and  seven 

9 


10 

months;  how  much  longer  infection  will  last  is  not  established.  If  a  patient  is  sub- 
ject to  cumulative  infection,  the  disease  may  last  five,  ten,  or  even  fifteen  years,  and 
in  case  of  light  infection  perhaps  longer. 

External  appearance. — In  extreme  cases  there  is  a  general  lack  of  development; 
skin  waxy  white  to  yellow  or  tan;  hair  is  found  on  the  head,  but  is  more  or  less 
absent  from  the  body;  breasts  are  undeveloped;  nails  white;  external  genitalia  more 
or  less  rudimentary;  face  anxious,  may  be  bloated;  conjunctive  pale;  eyes  more 
or  less  dry,  pupil  dilates  readily;  membranes  pale  according  to  the  anemia;  teeth 
often  irregular;  tongue  frequently  marked  with  purple  or  brown  spots;  cervical  pul- 
sations prominent;  thorax  emaciated;  heart  beats  often  visible;  abdomen  frequently 
with  "potbelly;"  extremities  emaciated,  frequently  edematous,  and  with  wounds 
or  ulcers  of  long  standing. 

Urine  1010  to  1015;  in  advanced  cases  albumin  without  casts;   acid  or  alkaline. 

Feces  reddish  brown,  contain  eggs,  and  may  contain  blood. 

Circulatory  system. — Anemia  pronounced,  according  to  degree  and  duration  of  infec- 
tion; blood  watery,  with  decreased  red  blood  corpuscles  and  with  eosinophilia; 
"heart  disease"  very  commonly  complained  of;  hemic  murmurs  present;  pulse  80 
to  132  per  minute. 

Temperature. — Subnormal,  normal,  or  to  101°  or  102°  F. 

Respiratory  system. — Breathing  may  be  difficult,  slow,  or  increased  to  as  high  as  30. 

Muscular  system. — Emaciation  and  great  physical  weakness. 

Digestive  system. — Appetite  poor  to  ravenous;  abnormal  appetite  often  developed 
for  pickles,  lemons,  salt,  coffee,  sand,  clay,  etc.;  pain  in  epigastrium;  constipation  or 
diarrhea. 

Nervous  system. — Headache,  dizziness,  nervousness,  mental  lassitude,  and  stupidity. 

Genital  system. — Menstruation  irregular  or  absent;  if  present,  it  occurs  chiefly  in 
winter;  there  is  a  marked  tendency  to  abortion. 

Diagnosis. — The  safest  plan  is  to  make  a  microscopic  examination  of  the  feces  to 
find  the  eggs;  or,  if  feces  are  placed  on  white  blotting  paper,  a  blood-like  stain  will 
be  noticed. 

Treatment. — Thymol,  or  male  fern  (or  ?  calomel);  iron,  and  good  food. 

Prognosis. — Good,  if  patient  is  not  too  far  gone  at  time  of  treatment. 

Lethality. — Not  yet  determined. 

Prevention. — Treat  all  cases  found  and  dispose  of  feces. 

Economically,  uncinariasis  is  very  important.  It  keeps  children  from  school, 
decreases  capacity  for  both  physical  and  mental  labor,  and -is  one  of  the  most 
important  factors  in  determining  the  present  condition  of  the  poorer  whites  of  the 
sand  and  pine  districts  of  the  South. 

The  disease  is  carried  from  the  farms  to  the  cotton  mills  by  the  mill  hands,  but 
does  not  spread  much  in  the  mills;  nevertheless,  it  causes  a  considerable  amount  of 
anemia  among  the  operatives. 


REPORT  UPON  THE  PREYALENCE  AND  GEOGRAPHIC 
DISTRIBUTION  OF  HOOKWORM  DISEASE  (UNCINARIA- 
SIS  OR  ANCHYLOSTOMIASIS)  IN  THE  UNITED  STATES. 

By  CH.  WARDELL  STILES,  Ph.  D., 

Chief  of  Division  of  Zoology,  Hygienic  Laboratory,  U.  S.  Public  Health  and  Marine- 
Hospital  Service. 

INTRODUCTION. 

Thoroughly  convinced  from  theoretical  zoologic  considerations, 
especially  of  a  faunistic  nature,  that  uncinariasis  must  be  a  more  or 
less  common  disease  in  the  Southern  portion  of  the  United  States, 
I  requested  instructions  from  Surgeon -General  Wyman  to  study 
the  subject  in  a  field  investigation.  The  desired  authorization  was 
received  and  the  results  of  the  work  are  contained  in  this  paper. 

DEFINITION. 

Uncinariasis  is  a  specific  zooparasitic  disease  found  especially  in 
tropical  and  subtropical  sand  areas,  and  caused  by  hookworms  (genus 
Uncinaria)  which  inhabit  the  small  intestine.  Its  chief  symptoms 
are:  Anemia,  with  the  circulatory  symptoms  found  in  all  extreme 
anemias,  namely,  dizziness,  palpitation,  hemic  murmurs;  great  weak- 
ness, in  some  cases  with  considerable  emaciation ;  colicky  pains  in  the 
abdomen;  perverted  appetite,  such  as  "dirt-eating;"  constipation  or 
diarrhea,  stools  sometimes  brownish  or  bloody;  nausea;  edema.  The 
only  positive  diagnosis  is  by  finding  the  parasite  or  its  eggs  in  the 
stools.  It  may  affect  any  class  of  patients,  but  is  more  frequent  in 
persons  whose  daily  life  brings  them  in  contact  with  damp  earth 
(children,  farmers,  miners,  brickmakers,  excavators,  etc.). 

TERMINOLOGY. 

The  disease  now  under  discussion  is  known  by*a  number  of  different 
names,  but  uncinariasis"  should  be  adopted  as  the  more  correct  tech- 
nical designation.  Among  the  names  frequently  applied  to  it,  the 

«Looss  (1902)  has  recently  attempted  to  suppress  the  term  "uncinariasis"  in 
favor  of  anchylostomiasis,  his  view  being  that  the  genus  Agchylostoma  is  distinct 
from  Uncinaria.  His  suggestion  does  not  help  matters  much  at  present.  Even  if 
the  zoological  genera  are  recognized  as  distinct,  uncinariasis  would  still  exist  in  man, 
while  among  animals  it  would  be  still  more  common  than  anchylostomiasie.  Further, 
the  two  genera  would  probably  have  to  be  united  in  a  subfamily,  which  could  then 
be  called  "Uncmariinse,"  and  uncinariasis  could  then  signify  any  infection  of  any 

11 


12 

following  may  be  mentioned  in  particular:  Anchylostomiasis,  ankylos- 
tomiasis,  brickmakers'  anemia,  Egyptian  chlorosis,  miners'  anemia, 
miners'  cachexia,  tunnel  anemia,  St.  Gothard  tunnel  disease,  tropical 
chlorosis,  hookworm  disease,  and  tunnel  disease.  (See  also  pp.  31,  32, 

96.) 

HISTORICAL  REYIEW. 

In  order  to  understand  the  exact  status  of  the  subject  of  uncinari- 
asis,  it  will  be  well  to  take  a  brief  historical  review  of  hookworms  in 
general,  hookworm  disease  in  general,  and  hookworm  disease  in  the 
United  States. 

BRIEF  REVIEW  OF  HOOKWORMS. 

It  is  quite  probable  that  the  ancient  Egyptians,  nearly  thirty -live 
hundred  years  ago,  were  acquainted  with  the  parasites  which  we  now 
call  hookworms.  From  a  zoological  Standpoint,  however,  the  first 
hookworm  known  to  science  was  a  parasite  in  the  intestine  of  the 
common  badger  (Meles  taxus)  of  Europe,  described  by  Gceze,  a  Ger- 
man clergyman,  in  1782.  Gceze  called  the  parasite  "der  Haarrund- 
wurm"  (the  hair  round  worm),  and  gave  to  it  the  Latin  name  Ascaris 
criniformis.  Although  he  placed  this  species  in  the  same  genus  with 
the  ordinary  eelworm,  Ascaris  lumbricoides,  he  intimated  that  it  rep- 
resented a  distinct  genus.  One  of  the  anatomical  characters  which 
Goaze  noticed  was  a  membranous  expansion  on  the  tail  of  the  male, 
and  in  this  he  saw  two  finger-  or  ray -like  structures  which  he  inter- 
preted as  "hooks"  (see  caudal  rays  in  figs.  1,  15). 

In  1789  Frcelich  found  a  similar  worm  in  the  common  fox  (Canis 
vulpes  or  Vulpes  vulpes)  of  Europe.  He  noticed  the  same  mem- 
branous expansion  and  "two  hooks  with  many  points"  on  the  end  of 
the  tail.  On  account  of  this  character  he  adopted  the  vernacular 
name  "Haakenwurm"  (hookworm),  and  proposed  the  generic  name 
Uncinaria  for  the  new  genus  which  he  established. 

It  is  now  known  that  the  membranous  expansion  is  the  caudal 
bursa,  found  in  all  members  of  the  family  Strongylidse,  while  the 
so-called  "hooks"  represent  the  "rays"  or  "ribs"  which  support  the 
bursa  (see  fig.  1).  In  the  early  part  of  the  nineteenth  century  several 
other  species  of  hookworms  were  described  as  parasitic  in  various 
animals,  and  they  were  united  generically  with  the  "colic  worms" 
(strongyles)  of  horses. 

animal  with  any  member  of  this  subfamily.  In  case  the  term  "anchylostomiasis  " 
is  adopted,  which  of  the  many  spellings  should  be  recognized?  Adopting  uncin- 
ariasis  relieves  us  of  the  necessity  of  discussing  that  point,  and  further  gives  to  the 
name  of  the  disease  the  same  orthography  in  several  different  languages.  The  case 
at  hand  gives  rise  to  the  question  whether  it  is  not  inadvisable  to  name  diseases 
after  the  zoological  names  of  the  parasites,  at  least  during  the  transitional  stage  of 
zoological  nomenclature.  As  a  matter  of  fact  it  is  the  function  of  the  medical  pro- 
fession, not  that  of  the  zoological,  to  determine  what  names  should  be  used  to  desig- 
nate diseases,  but  at  the  present  moment,  medical  terminology  is  subjective. 


13 


FIG.  1. — Caudal  bursa  of  a  male  strongyle 
( (Esophagostoma  dentatum),  to  serve  as 
diagram  for  the  family:  ?;.  r.,  ventral 
rays;  v.  1.  r.,  yentro-lateral  rays;  I.  r.,  lat- 
eral rays;  d.  I.  r.,  dorso-lateral  rays;  d.  r., 
dorsal  rays.  X  93.  (After  Schneider, 
1866,  p.  130.) 


In  1843  Dubini,  of  Milan,  Italy,  described  a  hookworm  as  parasitic 
in  man.  Besides  the  caudal  "hooks"  (i.  e.,  the  "rays")  of  the  male, 
Dubinins  parasite  presented  four  hooks  in  the  mouth.  It  presented 
further  an  anatomical  character  which  is  common  to  all  hookworms, 
namely,  the  Ventral  surface  of  the  an- 
terior end  grows  more  rapidly  than  the 
dorsal  surface,  so  that  the  oral  end  is 
bent  backward  like  a  "hook,"  and  the 
mouth  thus  occupies  a  dorsal  position. 
Thus  it  is  seen  that  the  original  char- 
acter which  led  to  the  vernacular  name 
"hookworm"  was  a  misinterpretation; 
the  second  character  of  "hooks"  (name- 
ly, in  the  mouth),  which  has  been  pop- 
ularly but  erroneously  interpreted  as 
responsible  for  the  vernacular  name 
"hookworm,"  is  not  present  in  all  spe- 
cies; the  hooklike  curvature  of  the  head 
is  usually  but  not  always  distinct.  I 
propose,  however,  to  retain  the  word  "hookworm"  as  a  vernacular  name. 

It  is  not  apparent  that  Dubini  knew  that  Frcelich  had  proposed  the 
genus  Uncinaria,  and  it  is  probably  on  this  account  that  he  proposed  a 
new  genus — Agchylostoma  by  name — to  contain  the  parasite  (Agchylo- 
stoma  duodenale)  which  he  had  found  in  man. 

For  years  it  was  supposed  that  this  was  the  only  species  of  hookworm 
found  in  man,  but  in  May,  1902,  I  showed  that  in  America  we  have  a 
distinct  species,  which  I  named  Uncinaria  americana. 

ZOOLOGICAL   POSITION    OP   THE    PARASITES. 

The  parasites  which  cause  uncinariasis  are  worms  belonging  to  the 
nematode  family  Strongylidse. 

Family  STRONGYLID.E. 

FAMILY  DIAGNOSIS.— Nematoda:  With  body  elongate,  cylindrical,  rarely  filiform. 
Mouth  is  probably  always  provided  with  six  papillae,  of  which  the  four  submedian 
are  generally  salient  in  form  of  nodules  or  conical  points.  In  some  cases  the  mouth  is 
in  the  axis  of  the  body;  in  others  it  is  turned  dorsally  or  ventrally,  and  occasionally 
provided  with  a  chitinous  armature.  Esophagus  more  or  less  swollen  in  posterior 
portion,  but  without  forming  in  adults  a  distinct  esophageal  bulb.  Male  provided 
with  a  caudal  bursa,  open  or  closed,  entire  or  divided,  and  with  one  or  two  spicules. 
Female  with  one  or  two  ovaries;  vulva  anterior  or  posterior  of  equatorial  plane,  in 
some  cases  near  the  anus.  Eggs  deposited  during  segmentation,  in  some  cases 
containing  embryo. 

TYPE  GENUS. — Strongylus  O.  F.  Mueller. 

The  sexes  are  separate  and  the  digestive  tract  is  complete.  Charac- 
teristic for  the  family  is  the  presence,  on  the  tail  of  the  male,  of  an 
umbrella-like  structure  known  as  the  caudal  or  "copulatory  bursa," 


14 

supported  by  a  number  of  finger-like  "rays."  which  may  be  compared 
to  the  ribs  of  an  umbrella.  In  coitu,  the  male  clasps  the  body  of  the 
female  by  means  of  this  bursa. 

This  family  is  divided  into  subfamilies,  according  to  the  presence  of 
certain  anatomical  characters.  The  parasites  of  uncinariasis  are  now 
classified  in  the  subfamily  Strongylinse,a  which,  as  its  former  name, 
Sclerostominse,  indicated,  is  characterized  by  the  presence  of  a  hard 
chitinous  "buccal  capsule." 

Subfamily  STRONG- YLI^T.^:. 

SUBFAMILY  DIAGNOSIS. — Strongylidse:  Meromyaria;  mouth  with  mtore  or  less  com- 
plete chitinous  armature.  Male  with  two  equal  spicules;  caudal  bursa  with  rays, 
the  dorsomedian  and  dorsolateral  being  united  in  a  common  base.  Female  with 
two  ovaries,  except  in  Ollulanus. 

TYPE  GENUS. — Strongylus  Mueller. 

The  subfamily  Strongylinse  is  in  turn  divided  into  a  number  or 
genera,  of  which  we  may  mention  here  the  following: 

Strongylus  [Sclerostoma];  the  sclerostomes,  including  the  colic  worms 
of  horses  and  the  kidney  worms  of  hogs  (but  not  the  kidney  worms  of 
dogs  and  man); 

Syngamus,  including  the  gape  worms  of  chickens;  and 

Uncinaria,  the  hookworms,  including  the  parasite  of  uncinariasis. 

It  seems  very  probable  that  hookworms  will  have  to  be  divided  into 
several  different  genera,  for  which  a  new  subfamily  will  perhaps  be 
recognized,  but  it  is  not  quite  clear  at  present  just  what  genera  will 
be  admitted.  Undoubtedly  Uncinaria  Froelich,  1789,  must  be  adopted 
for  one,  and  in  this  will  probably  be  placed  worms  like  Uncinaria 
stenocephala,  possessing  ventral  lips  but  not  ventral  recurved  teeth. 
It  is  quite  possible  that  a  second  genus  (Monodontus  Molin,  1861,  or 
Bunostomum  Railliet,  1900)  will  be  recognized  for  certain  other 
forms,  with  buccal  lips  and  with  the  prominent  dorsomedian  buccal 
tooth,  as  was  proposed  by  Molin;  probably  the  new  American  hook- 
worm will  be  placed  in  this  genus.  Hookworms  with  the  ventral 
recurved  buccal  teeth,  as  seen  in  Uncinaria  duodenalis  and  TJncinaria 
canina  will  probably  be  separated  into  a  distinct  genus,  for  which 
Dubini's  name  Agchylostoma  will  be  available.  To  satisfactorily 
determine  the  points  at  issue  will  require  further  anatomical  study  of 
a  number  of  different  species.  For  the  purpose  of  this  paper  it  will 
be  sufficient  to  call  attention  to  these  probable  changes. 

«From  a  study  of  the  history  of  the  nematode  genera,  it  is  very  clear  that  there 
will  have  to  be  a  general  revision  of  the  technical  names  of  this  group.  The  original 
Strongylus,  for  instance,  was  a  sclerostome,  hence  the  names  Sclerostoma  and  Sclerosto- 
minse  will  have  to  fall  into  synonymy.  It  i$  probable  that  Metastrongylus  will  be  the 
correct  name  for  the  lung  strongyles.  Strongylus  contorlus  becomes  Hsemonchm 
contortus.  As  soon  as  certain  remaining  points  of  this  nature  are  decided,  Hassall 
and  I  will  issue  a  list  of  nematode  genera,  together  with  their  type  species. 


15 


Genus  UNCINARIA"  Froelich,  1789. 

GENERIC  DIAGNOSIS. — Strongylinse:  With  anterior  extremity  curved  dorsally;  mouth 
round  to  oval,  opening  oblique,  limited  by  a  transparent  border  and  followed  by  a 
chitinous  buccal  capsule;  the  dorsal  portion  of  the  capsule  is  shorter  than  the  ventral, 
and  is  supported  by  a  conical  structure,  the  point  of  which  sometimes  extends  into 
the  cavity;  at  the  base  of  the  buccal  capsule  are  found  two  ventral  teeth;  toward 
the  inner  free  border  the  ventral  wall  bears  on  each  side  of  the  median  line  chitin- 
ous structures,  lips  (  Uncinaria)  or  teeth,  often  recurved  in  shape  of  hooks  (Agchylo- 
stoma} ;  the  inner  dorsal  wall  may  also  bear  lips  or  teeth.  Oviparous,  eggs  with  thin, 
transparent  shell. 

TYPE  SPECIES. —  Uncinaria  vulpis  b  Froelich,  1789. 

«  SYNONYMY,  WITH  ORIGINAL  PLACE  OF  PUBLICATION. 

1789:  Uncinaria  FRO3LiCH<Der  Naturforscher,  Halle,  v.  24,  pp.  130-139;  type,  Unci- 
naria vulpis  Froelich,  1789. 

1799:  Undaria  FiscHER<Arch.  f.  d.  Physiol.,  Halle,  v.  3,  p.  99.  [Apparently  a 
misprint  for  Uncinaria.  ] 

1843:  Agchylostoma  DuBiNi<Annal.  univers.  di  medic..  Milano,  v.  106,  aprile,  pp. 
5-13;  type,  Agchylostoma  duodenale  Dubini,  1843. 

1845:  Ancylostoma  CREPLiN<Archiv  f.  Naturg.,  Berlin,  11.  J.,  v.  1,  p.  325;  for  Agchy- 
lostoma Dubini,  1843. 

1845:  Dochmius  DUJARDIN,  Histoire  naturelle  d.  helminthes,  pp.  267,  275-279;  type, 
Uncinaria  vulpis  Froelich,  1789. 

1845:  Docmius  DUJARDIN,  ibidem,  p.  114.     [Misprint  for  Dochmius.'] 

(1846):  Anchylostoma  DELLE  CmAJE<Rendicon.  dell'Accad.  delle  Sci.  Napoli,  v.  5, 
p.  339.  [Not  verified.] 

1850:  Anchylostoma  DUBINI,  Entozoografia  umana,  pp.  102-112;  for  Agchylostoma 
Dubini,  1843. 

1851:  Ancylostomum  DIESING,  Systema  helminthum,  v.  2,  p.  82;  for  Agchylostoma 
Dubini,  1843. 

1851:  Anchylostomum  DIESING,  Systema  helminthum,  v.  2,  pp.  321-322;  for  Agchy- 
lostoma Dubini,  1843. 

1861:  Monodontus  MOLIN  (not  Monodonta  Lamarck,  1799),  II  sottordine  degli  acrofalli 
<Mem.  r.  1st.  ven.  di  sc.,  lett.  ed  arti,  Venezia,  v.  9,  pp.  435,  463-470;  type, 
M.  semicircularis  Molin,  1861. 

1861:  Doohmius  MoLiN<Ibidem,  p.  471.     [Misprint  for  Dochmius.] 

1862:  Dac/wims<Veterinarian,  Lond.  (416),  v.  35,  4.  s.  (92),  v.  8,  Aug.,  pp.  549-556. 
[Misprint  for  Dochmius.  ~\ 

1879:  Anchilostoma  BozzoLO<Osservatore,  Torino,  v.  15  (24),  17  giugno,  pp.  369-370; 
for  Agchylostoma  Dubini,  1843. 

1895:  Ankylostomum  8TossiCH<Boll.  Soc.  Adriatica  di  sc.  nat.  in  Trieste,  v.  16,  pp. 
21-25;  for  Agchylostoma  Dubini,  1843. 

18 — ?:   "  A nkylostoma  Dubini"  of  various  authors;  for  Agchylostoma  Dubini,  1843. 

1897:  Anchylostamum  MCEHLAU< Buffalo  M.  J.,  v.  36  (8),  Mar.,  p.  573.  [Misprint  for 
Anchylostomum.] 

1902:  Dohmius  Looss<Centrabl.  f.  Bakteriol.,  Parasitenk.  [etc.],  Jena,  1  Abt.,  v.  31 
(9),  5.  Apr.,  Originale,  p.  424.  [Misprint  for  Dochmius.] 

1902:   Unicinaria  VON  LiNSTOw<Zool.  Centralbl.,  Leipz.,  v.  9  (24-25),  16.  Dec.,  p.  778. 

[Misprint  for  Uncinaria.  ] 
&This  species  is  probably  identical  with  Uncinaria  melis  Froelich,  1789;  Ascariv 

criniformis  Goeze,  1782,  and  with  Uncinaria  stenocephala  (Railliet,  1884). 


16 

The  anatomical  character  which  distinguishes  the  genus  Uncinaria 
is  the  dorsal  curvature  of  the  anterior  extremity  of  the  body,  due  to 
the  shortness  of  the  dorsal  wall  of  the  buccal  capsule  and  resulting  in 
bringing  the  mouth  into  a  dorsal  instead  of  a  terminal  or  a  ventral 
position. 

In  many  medical  writings  this  genus  is  named  Anchylost-oma,  a  word 
which  is  spelled  in  at  least  nine  different  ways,  and  the  disease  is 
spoken  of  as  anchylostomiasis.  This  nomenclature  and  terminology 
are  due  to  the  fact  that  when  the  hookworm  ( Uncinaria  duodenalis)  of 
man  was  first  described,  in  1843,  it  was  supposed  to  represent  a  new 
genus  (Agchylostomd).  As  a  matter  of  fact,  however,  it  is  generally 
acknowledged  to  be  congeneric  with  a  worm  described  in  1789  as 
Uncinaria.  By  the  international  "law  of  priority,"1'  therefore,  the 
names  Agchylostoma,  Anchylostoma,  etc. ,  fall  into  synonymy  until  it 
can  be  shown  that  the  two  species  are  not  congeneric.  (See  p.  14.) 

In  explanation  to  physicians  it  may  be  here  stated  that  zoologists 
are  obliged  to  deal  with  hundreds  of  thousands  of  technical  names, 
and  on  this  account  they  have  been  forced  to  adopt  very  rigid  rules 
governing  their  use.  Our  most  important  rule  is  the  "law  of  prior- 
ity,"'which  to  us  is  as  essential  as  is  the  "code  of  ethics"  to  the 
physician. 

The  genus  Uncinaria  contains  blood-sucking  worms  of  the  worst 
type.  They  are  usually  not  over  an  inch  in  length  nor  thicker  than 
an  ordinary  hatpin.  They  are  provided  with  a  heavy  armature  of 
sharp  teeth,  by  means  of  which  they  pierce  the  intestinal  mucosa  of 
their  host.  They  have  also  an  unusually  strong  muscular  esophagus, 
which  serves  as  a  pump  during  the  act  of  sucking  blood.  An  important 
point,  from  the  medical  aspect  of  the  parasites,  is  that  they  do  not 
remain  fastened  to  one  spot  in  the  bowels,  but  suck  first  at  one  spot 
and  then  at  another.  Thus  the  patient  loses  blood  directly  to  the 
parasites,  and  also,  by  numerous  minute  hemorrhages,  into  the  intes- 
tine. It  is  probably  this  latter  factor  which  occasionally  gives  to  the 
stools  of  patients  that  peculiar  reddish-brown  tinge,  and  also  their 
occasional  bloody  appearance. 

The  injury  to  the  intestinal  wall  does  not  stop  with  the  bite.  The 
wound  forms  an  excellent  point  of  attack  for  bacteria,  and  the  intes- 
tinal wall  becomes  thickened,  thus  losing,  to  a  greater  or  lesser  degree, 
the  ability  properly  to  perform  its  function.  Not  only  does  the  patient 
lose  blood,  but  his  power  of  assimilation  is  impaired,  and  the  supply 
of  blood-forming  material  is  thus  in  part  cut  off.  Some  authors  also 
claim  that  the  parasites  produce  a  poison  which  acts  upon  the  system, 
a  view  which  is  very  strongly  supported  by  certain  clinical  facts. 

It  was  stated  above  that  hookworms  are  found  in  various  animals. 
Now,  the  general  rule  may  be  laid  down  that  where  these  worms  are 
present  trouble  uia}r  be  expected. 


17 

Uncinaria  americana  and  Agchylostoma  duodenale  cause  in  man  the 
disease  variously  known  as  uncinariasis,  uncinariosis,  anchylostomiasis, 
tunnel  disease,  miners'  anemia,  brickmakers'  anemia,  mountain  ane- 
mia, etc. 

Agchyloxtoma  caninum  '[Uncinaria  caninaa\  causes  a  similar  disease 
in  dogs,  resulting,  in  some  parts  of  the  country,  in  a  death  rate  of 
from  25  to  40  per  cent  of  the  pups  born.  Uncinariasis  in  dogs  is 
exceedingly  common  in  Washington,  D.  C.  "Typhoid"  in  cats  is 
attributed  to  this  parasite. 

Instructors  in  medical  colleges  who  wish  to  demonstrate  hookworms 
and  their  eggs  to  the  students  will  find  A.  caninum  of  dogs  an  excel- 
lent substitute  for  Agchylostoma  duodenale  of  man  in  case  the  latter 
species  can  not  be  obtained. 

Uncinaria  stenocephala  occures  in  dogs,  foxes,  and  allied  animals, 
and  is  causing  considerable  trouble  in  the  blue  fox  ( Vulpes  lagopus) 
industry. 

Uncinaria  trigonocepJialab  is  found  in  sheep  and  produces  a  serious 
anemia.  This  parasite  has  been  met  in  Victoria  and  Calhoun  counties, 
Tex.,  where,  in  conjunction  with  the  twisted  wireworm  (Hsem,onchus 
contort ''us c),  it  has  caused  the  death  of  from  25  to  50  per  cent  of  certain 
flocks. 

Uncinaria  radiatad  is  found  in  cattle,  producing  trouble  just  below 
the  stomach.  The  writer  has  collected  this  parasite  in  Dewitt, 
Gonzales,  Victoria,  and  Calhoun  counties,  Texas,  and  has  seen  speci- 
mens from  Florida  collected  by  Dr.  C.  F.  Dawson. 

Uncinaria  Lucasi  was  found  several  years  ago  in  the  seal  pups  of 
Alaska  by  Mr.  Lucas,  after  whom  the  worm  has  been  named.  It  is 
responsible  for  about  17  per  cent  of  the  deaths  of  the  pups. 

Still  other  species  of  hookworms  are  reported  for  other  animals. 

None  of  the  species  from  animals  mentioned  above  is  known  to  affect 
man,  nor  has  either  Uncinaria  americana  or  Agchylostoma  duodenale 
of  man  been  satisfactorily  demonstrated  to  occur  normally  in  other 
hosts  than  man. 

«This  is  Uncinaria  canina  (Ercolani  1859)  Railliet,  1900,  a  parasite  of  canines  and 
felines,  which  is  usually  known  as  Uncinaria  trigonocephala  (Rudolphi,  1809)  Railliet, 
1885  [not  Uncinaria  trigonocephala  (Rudolphi,  1809)  Railliet,  1900].  If  Uncinaria 
and  Agchylostoma  are  recognized  as  distinct,  U.  canina  should  be  placed  in  the  same 
genus  as  U.  duodenalis.  I  have  not  yet  tested  the  correctness  of  the  specific  name 
canina  for  this  form,  but  it  is  here  accepted  on  authority  of  Railliet. 

&  This  is  Uncinaria  trigonocephala  (Rudolphi,  1809)  Railliet,  1900  [not  "U.  trigono- 
cephala Rudolphi,  1809)"  Railliet,  1885].  Both  Railliet  and  I  have  recently  exam- 
ined Rudolphi' s  original  material,  and  it  is  unquestionably  identical  with  U.  cernua 
(Creplin,  1829)  of  sheep.  This  species  is  closely  related  to  U.  americana. 

c  Strongylns  contortus  Rudolphi. 

d  Bunostomum  phlebotomum  Railliet. 

19558— No.  10—03 2 


18 


FIG.  2.— New  World  male  hookworm  (  Uncinaria  americana).  Natural  size.  (After  Stiles,  1902b,  p.  190, 
FIG.  3.— New  World  female  hookworm  (  Uncinaria  americana}.  Natural  size.  (After  Stiles,  1902b,  p. 
FIG.  4.— The  same,  enlarged  to  show  the  position  of  the  anus  (a)  and  the  vulva  (v).  After  Stiles,  1902b, 

FIG.  5.— Dorsal  view  of  anterior  end  of  New  World  hookworm  ( Uncinaria  americana):  b.  c.,  buccal 
cavity;  c.p.,  cervical  papillae;  d.  m.  t.,  dorsal  median  tooth,  projecting  prominently  into  the  buccal 
cavity;  d.  sm.  I.,  small  dorsal  semilunar  lip;  e.,  esophagus;  m.  in.,  margin  of  mouth,  the  prominent 
oval  opening  seen  upon  high  focus;  p.  p.,  papillae;  v.  sm.  I.,  large  ventral  semilunar  lips  homologous 
with  the  ventral  hooks  of  A.  duodenale.  Greatly  enlarged.  (After 'Stiles,  1902b,  p.  190,  fig.  123.) 

FIG.  6. — Lateral  view  of  anterior  end  of  New  World  hookworm  ( Uncinaria  americana):  b.  c.,  buccal  cav- 
ity; d.m.t.,  dorsal  median  tooth,  projecting  prominently  into  buccal  cavity ;  e.,  esophagus;  m.m.,  mar- 


FIG         

showing  the  arrangement  of  the  rays.    Note  the  short  dorsal  lobe.    Greatly  enlarged.     (After 
Stiles,  1902b.  p.  190,  fig.  125.) 


Fm.  8.— The  caudal  end  of  the  New  World  male  hookworm  (Uncinaria  americana).  The  bursa  is 
spread  out  to  show  the  arrangement  of  the  rays.  Note  the  short  dorsal  lobe  which  is  subdivided, 
forming  two  lobes;  note  also  the  indistinct  ventral  lobe  connecting  the  two  lateral  lobes.  The 
dorsal  lobe  is  thrown  back  over  the  body.  Greatly  enlarged.  (After  Stiles,  1902b,  p.  191,  fig.  126.) 

[UNCINARIA  Frcelich,  1789,  sensu  stricto]. 

is. —  Unqinaria  s.  1.  with  buccal  lips. 
TYPE  SPECIES.  —  Uncinaria  vulpis  Frcelich. 

The  New  World  hookworm— UNCINARIA  AMERICANA"  Stiles,  1902— of  man. 

(Figures  2  to  9.) 

''  SPECIFIC  DIAGNOSIS. — Uncinaria:  Body  cylindrical,  somewhat  attenuated  ante- 
riorly. Buccal  capsule  with  a  dorsal  pair  of  prominent  semilunar  plates  or  lips, 
similar  to  U.  stenocephala,  and  a  ventral  pair  of  slightly  developed  lips  of  the  same 
nature;  dorsal  conical  median  tooth  projects  prominently  into  the  buccal  cavity, 
similar  to  Monodontus.  Male,  7  to  9  mm.  long;  caudal  bursa  with  short  dorso-median 
lobe,  which  often  appears  as  if  it  were  divided  into  two  lobes,  and  with  prominent 
lateral  lobes  united  ventrally  by  an  indistinct  ventral  lobe;  for  rays,  see  figures 
7-8;  common  base  of  dorsal  and  dorso-lateral  rays  very  short;  dorsal  ray 
divided  to  its  base,  its  two  branches  being  prominently  divergent  and  their  tips 
being  bipartite;  spicules  long  and  slender.  Female,  9  to  11  mm.  long;  vulva  in 
anterior  half  of  body,  but  near  equator.  Eggs,  ellipsoid,  64  to  76  jn  long  by  36  to 
40  yu  broad,  in  some  cases  partially  segmented  in  utero,  in  other  (rare)  cases  con- 
taining a  fully  developed  embryo  when  oviposited. 

HABITAT. — Small  intestine  of  man  (Homo  sapiens)  in  America  (determined  to  date, 
for  Virginia,  North  and  South  Carolina,  Georgia,  Florida,  Alabama,  Texas,  Porto 
Rico,  Cuba,  and  Brazil) . 

TYPE  SPECIMENS.— No.  3310,  B.  A.  I.,  U.  S.  Dept.  Agric. 

a  SYNONYMY  WITH  ORIGINAL  PLACE  OF  PUBLICATION. 

1902:   Uncinaria  americana  STILES  <Arn.  Med.,  Phila.,  v.  3  (19),  May  10,  pp. 777-778. 
1902:   Unicinaria  americana  (Stiles)   VON  LINSTOW  <Zool.  Centralbl.,    Leipz.,  v.    9 
(24-25),  16.  Dec.,  p.  778.     [Misprint.] 


20 


LIFE  HISTORY  OF  UNCINARIA  AMERICANA. 

The  life  history  of  the  American  hookworm  has  not  yet  been  deter- 
mined in  detail,  but  there  is  no  reason  for  assuming  that  it  will  differ 
radically  from  that  of  Agcliylostoma  duodenale  (see  p.  24.) 

In  my  first  description  of  the  worm  I  stated  that  the  egg  in  the 
uterus  may  occasionally  contain  an  embryo.  Since  making  this  obser- 
vation on  the  females  sent  to  me  by  Dr.  Allen  J.  Smith  I  have  exam- 
ined hundreds  of  fresh  eggs,  but  have  not  found  any  containing 

developed  embryos.  The  question  may 
therefore  legitimately  arise  whether 
the  females  originally  examined  were 
not  exposed  to  the  air  for  some  time 
before  they  were  preserved,  thus  mak- 
ing the  development  of  the  eggs  pos- 
sible. If  the  embryo  does  develop  in 
the  uterus,  as  indicated  by  some  of  Dr. 
Allen  J.  Smith's  material,  such  an  oc- 
currence is  undoubtedly  rare. 

DEVELOPMENT   OUTSIDE    THE    BODY. 

Segmentation. — In  feces  exposed  to  a 
September,  October,  or  earty  November 
temperature  of  the  Carolinas,  Georgia, 
and  Florida,  the  embryo  develops  in 
the  egg  (fig.  9)  in  about  one  day's  time. 
In  some  instances  the  embryo  develops 
in  less  than  24:  hours.  It  is  a  com- 
mon occurrence  to  find  feces  24  hours 
old  containing  free  embryos. 
The  conditions  under  which  the  trip  was  made  were  not  favorable 
to  exact  observation  in  regard  to  temperature,  moisture,  etc.  It  was, 
however,  possible  to  find  worms  in  their  first  ecdysis  about  2  to  3  days 
after  hatching,  and  worms  in  the  second  ecd^^sis  about  7  to  9  days 
after  hatching.  These  observations  were  made  under  most  unfavor- 
able circumstances,  when  careful  measurements,  drawings,  etc.,  were 
excluded,  hence  they  should  be  repeated. 

DEVELOPMENT    INSIDE    THE    BODY. 

Experimental  infections  during  the  trip  were,  of  course,  impossible. 


FIG.  9.— Four  eggs  of  the  New  World 
hookworm,  Uncinaria  americana,  in 
the  1,  2,  and  4  cell  stages.  The  egg 
showing  3  cells  is  a  lateral  view  of  a 
4-cell  stage.  These  eggs  are  found  in 
the  feces  of  patients  and  give  a  positive 
diagnosis  of  infection.  Greatly  en- 
larged. (After  Stiles,  1902b,  p.  192,  fig. 
127.) 


21 

[AGCHYLOSTOMA  «  Dubini,    1843.] 

DIAGNOSIS. —  Undnaria:  Provided  with  ventral  recurved  teeth. 

TYPE  SPECIES. — Agchylostoma  duodenale  Dubini,  1843. 

The  Old  World  hookworm— AGCHYLOSTOMA  DUODENALE  &  Dubini,  1843,  or  UNCINAKIA 
DUODENALIS  (Dubini)  Eailliet,  1885— of  man. 

(Figures  10  to  41.) 

SPECIFIC  DIAGNOSIS. — Agchylostoma:  Body  cylindrical,  somewhat  attenuated  ante- 
riorly. Buccal  cavity  with  two  pairs  of  ventral  teeth  curved  like  hooks,  and  one 
pair  of  dorsal  teeth  directed  forward;  dorsal  rib  not  projecting  into  the  cavity. 
Male,  8  to  11  mm.  long;  caudal  bursa  with  dorso-median  lobe,  and  prominent  lateral 
lobes  united  by  a  ventral  lobe;  for  rays,  see  fig.  14;  dorsal  ray  divides  at  a  point 
two-thirds  its  length  from  ita  base,  each  branch  being  tridigitate;  spicules  long  and 
slender.  Female,  10  to  18  mm.  long;  vulva  at  or  near  posterior  third  of  body.  Eggs, 
ellipsoid,  52  to  60  ju  by  32  JLI,  laid  in  segmentation.  Development  direct  without  inter- 
mediate host. 

'?There  are  numerous  ways  of  spelling  this  word  (see  p.  15),  more  than  one  with 
moiv  or  less  philological  authority.  Under  these  circumstances  I  adopt  the  original 
orthography,  despite  the  fact  that  it  is  not  philologically  correct.  By  this  action  I 
do  not  intend  to  necessarily  reject  the  ruling  covered  by  the  International  Code,  but 
from  practical  experience  I  find  it  impracticable  to  carry  out  said  rule  in  reference 
to  the  emendation  of  names  until  the  question  of  homonyms  is  decided. 

^SYNONYMY,  WITH  ORIGINAL  PLACE  OF  PUBLICATION. 

1843:  Agchylostoma  duodenale  DUBINI  <Ann.  univer.  di  med.,  Milano,  T.  106,  aprile, 

pp.  5-13,  pi.  1,  figs.  1-5;  pi.  2,  figs.  1-3. 
1845:  Ancylostoma  duodenale  (Dubini)  CREPLIN  <Arch.  f.  Naturg.,  BerL,  11.  J.,  v.  1, 

p.  325. 
(1846):  Anchylostoma  duodenal^   (Dubini)  DELLE  CHIAJE  <Rendicon.  dell'  Accad. 

delle  sci.,  Napoli,  v.  5,  p.  339.     [Not  verified.] 

1850:  Anchylostoma  duodenale  (Dubini)  DUBINI,  Entozoografia  umana,  pp.  103-112. 
1851 :  Anchylostomum  duodenale  (Dubini)  DIESING,  Systema  helminthum,  v.  2,  p.  322. 
?(1851) :  Strongylus  quadridentatas  SIEBOLD  <Naturforsch.  Versamml.  z.  Gotha.     [Not 

verified.] 
1861:  Dochmius  anchylostomum  MOLIN,  II  sottordine  degli  acrofalli  <Mem.   r.   1st. 

ven.  di  sc.,  lett.  ed  arti,  Venezia,  v.  9,  pp.  485-487. 

1864:  Sclerostoma  duodenale  (Dubini)  COBBOLD,  Entozoa,  pp.  361-362,  fig.  77. 
1866:  Strongylus  duodenalis  (Dubini)  SCHNEIDER,  Monographic  der  Nematoden,  BerL, 

pp.  139-140,  1  fig.,  pi.  9,  fig.  3. 
1866:  "Ancylostomum  duodenate  Dubini"  of  WHITE  <Boston  M.  &  S.  J.,  v.  75  (21), 

Dec.  20,  p.  427.     [Misprint  for  duodenale,] 
1876:  Dochmius  duodenalis  (Dubini)  LEUCKART,  Die  menschlichen  Parasiten,  v.  2  (3), 

pp.  410-460,  figs.  235-239,  241-247,  249. 
1879:  Anchilostoma  duodenale  (Dubini)   BOZZOLO  <0sservatore,  Torino,  v..  15  (24), 

17  giugno,  pp.  369-370. 
1881:  Docmius  duodenalis  <Rev.  med.  de  la  Suisse  Rom.,  Geneve,  v.  1  (3),  15  mars, 

p.  190. 
1885:   Undnaria  duodenalis  (Dubini)  RAILLIET,  Elements  de  zool.  med.  etagric.,  Par., 

pp.  357-359,  figs.  245-248. 
1897:  Anchylostamum  duodenale  (Dubini)  MCEHLAU  < Buffalo  M.  J.,  v.  36  (8),  Mar., 

pp.  573-579.     [Misprint  for  Anchylostomum  duodenale.] 
Ankylostoma  tlnodetia/e  and  Ankylostomum  duodenale  of  various  authors. 


22 


cut 


FIG.  10.— Dorsal  view  of  anterior  end  of  the  Old 
World  hookworm  (Agchylostoma  duodenale)  of 
man.  Greatly  enlarged.  (After  Perroncito, 
1882,  p.  339,  fig.  140.) 


FIGS.  11-12.— Old  World 
male  and  female 
hookworms  (Agchy- 
lostoma duodenale)  of 
man.  Natural  size. 
(After  Stiles,  1902b, 
p.  187,  tigs,  lift,  llfi.1 


FIG.  14. — Semidiagramrnatic  figure  of  the  caudal 
bursa  of  an  Old  World  male  hookworm  (Agchylo- 
stoma duodenale)  of  man.  (After  Railliet,  1886,  p. 
357,  fig.  247.) 


FIG.  13.— Old  World  fe- 
male hookworm  (.!(/- 
Chyloxtonia  ihnxli  IHI/I  ) 
of  man,  greatly  en- 
larged diagram  to 
show  the  anatomy: 
a.,  anus;  b.  c.,  buc- 
cal  capsule;  cnl.,  cul 
de  sac  of  ovary;  c., 
esophagus;  int.,  intes- 
tine; u.  a.  anterior  ut- 
erus; 11.  p.,  posterior 
uterus;  v.,  vulva  and 
vagina.  (AfterSchul- 
thess  [copied  from 
Blanchard,  1888a,  p. 
761,  tig.  374].) 


HABITAT. — In  small  intestine  of  man  (Homo  sapiens)',  also  alleged  to  occur  in 
certain  apes.     Africa,  Europe,  Asia,  Philippines,  introduced  into  America. 


FIG.  15. — Male  hookworm  (Agchylostoma  duodenale)  of  man;  ac.  p., 
accessory  piece  to  spicules;  a.  p.,  "anal  papilla;"  6.  c.,  buccal  cap- 
sule; can.  cerv.  gl.  s.,  canal  of  left  cervical  gland;  cerv.  gl.  d.,  right 
cervical  gland;  cerv.  gl.  s.,  left  cervical  gland:  cu.,  cuticle,  cul.,  cul 
de  sac  of  testicular  tube;  e.,  esophagus;  e',  posterior  end  of  esopha- 
gus; e.  p.,  yentromedian  excretory  pore;  ej.  can.,  ejaculatory  canal; 
int.,  intestine;  1.  r.,  lateral  ray  of  bursa;  m.,  muscular  layer;  p.,  lat- 
eral prsecaudal  papilla;  sp.,  spicules;  spr,  anterior  end  of  spacules; 
test.,  testicular  tube;  ves.  sem.,  vesicula  seminalis;  v.  r.,  ventral  rays 
of  bursa.  Greatly  enlarged.  ( After  Schulthess  [copied  from  Blanch- 
ard,  1888a,  p.  755,  fig.  370].) 


24 


LIFE  HISTORY  OF  AGCHYLOSTOMA  DUODENALE    OR    UNCINARIA 

DUODENALIS. 

The  eggs  (tig.  16)  are  laid  in  the  intestinal  tract  of  the  patient  by 
the  female  worms  and  are  discharged  in  the  feces,  either  unsegmented 

or  during  the  early  stages  of  seg- 
mentation. They  will  not  develop 
into  adult  worms  in  the  intestine, 
but  must  first  pass  out  of  the  body. 
Thus,  for  every  adult  hookworm 
present  in  the  bowels  a  separate 
germ  must  enter  the  body. 

The  egg  has  a  thin  shell,  which  is 
an  indication  of  a  simple  life  cycle. 
A  short  time  after  escaping  in  the 
feces — the  time  varying  according 
to  temperature,  moisture,  and  posi- 
tion in  the  feces — each  egg  devel- 
ops (figs.  17-27)  a  minute  embryo, 
which  is  known  as  a  rhabditiforrn 
embryo  (fig.  27).  This  name  is  given 
to  it  because  of  its  resemblance  to 
worms  of  the  genus  Rhabditis.  Characteristic  for  this  stage  is  the 
rhabditif orm  esophagus,  which  is  entirely  different  from  the  esophagus 


FIG.  .16. — Eggs  of  Old  World  hookworms 
(Agchylostoma  duodenale)  as  found  in  the 
stools.  Greatly  enlarged.  (After  Stiles, 
1902b,  p.  193,  fig.  128.) 


FIGS  17-29.— Embryology  of  the  Old  World  hookworm  (Agchylostoma  duodenale)  of  man;  17-23,  seg- 
mentation of  the  egg,  24-26,  the  embryo;  27,  a  rhabditiform  embryo  escaping  from  its  eggshell;  28-29, 
empty  eggshells.  Greatly  enlarged.  (After  Perroncito,  1882,  p.  342,  fig.  142.) 

of  the  adult  hookworm.     This  embryonal  esophagus  is  more  or  less 
bottle   shaped,    and   consists   of  three   parts — an   anterior  elongated 


25 


swollen  portion,  followed  by  a  thin  middle  portion,  the  latter  being 
followed  by  a  more  or  less  globular  esophageal  bulb  which  possesses  a 
triradiate  chitinous  armature.  This  kind  of  esophagus  is  common  to 
the  early  stage  of  all  members  of  the  family  Strongylida?  and  also  to 
numerous  other  free-living  or  parasitic  nematodes.  It  is  evidently  a 
worm  with  an  esophagus  of  this  sort 
which  was  recently  found  in  the  earth 
taken  from  the  New  York  tunnel  ex- 
cavations, and  upon  which  was  based 
the  report  that  uncinariasis  was 
'  .present. 

The  embryo  of  the  hookworm  lives 
in  water  or  moist  ground.  In  its 
evolution  the  worm  casts  its  skin 
four  times,  thus  passing  through 
five  stages,  and  changes  its  structure 
so  as  to  assume  more  and  more  the 
characters  of  the  adult.  During 
these  changes  the  sexes  become  dif- 
ferentiated. Some  of  these  changes 
occur  in  water  or  moist  ground,  and 
the  rest  after  infection  takes  place. 

DEVELOPMENT  OUTSIDE  THE    BODY. 


The  eggs  develop 
best  in  the  unaltered  fecal  matter, 
especially  when  this  is  well  formed; 
not  so  well  when  it  is  more  fluid  in 
character.  The  addition  of  water 
retards  the  development,  and  if  con- 
siderable water  is  added  the  eggs 
perish.  Air  is  necessary  to  develop- 
ment, and  the  eggs  nearer  the  sur-- 
face  of  the  feces  segment  more  rap- 
idly than  those  in  the  center.  At  a 
temperature  of  about  27°  C.  the  em- 
bryo may  form  and  escape  from  the 
shell  in  twenty-four  hours.  Lower 
temperatures  retard  development,  so 
that  at  21°  or  22°  C.  the  embryo  may  not  escape  for  from  thirty-six 
to  forty  hours;  1°  C.  kills  the  eggs  in  twenty-four  to  forty-eight 
hours,  so  that  freezing  weather  may  be  looked  upon  as  disinfecting 
areas  exposed  to  the  cold. 

Embryo. — Upon  escaping  from  the  shell,  the  embryo  (tig.  27)  meas- 


FIGS.  30-31.— Two  larvae  of  the  Old  World 
hookworm  at  the  end  of  the  second  stage 
("encysted  larvae"),  representing  the 
young  worms  retracted  from  their  skin. 
(After  Perroncito,  1882,  p.  350,  figs.  148  a-b.) 


ures  0.3  mm.  in  length;  the  anterior  end  is  blunt,  the  tail  long  and 
pointed;  6  points  are  visible  around  the  mouth,  and  these  develop 
later  into  the  papillae;  jthe  buccal  cavity  is  10  jw  long,  1.4  /^  in  diameter, 
and  possesses  a  highly  refractive  chitinous  membrane;  the  anus  is  50  /* 
from  the  tip  of  the  tail;  excretory  pore  50  /*  from  anterior  end;  160 
ju  from  anterior  end  is  seen  the  primordium  of  the  genital  system. 
In  this  stage  the  embryo  takes  food  and  grows.  About  the  second 


...ft.  m. 


32 


FIG.  32.— A  young  hookworm  (Agchylostoma  duodenale)  of  man,  without  buccal  capsule,  four  days 
after  infection:  a,  anus;  c.  g.,  cervical  gland;  g,  primordium  of  genital  organs;  n.  s.,  nervous  sys- 
tem; p.,  papillae  on  head;  p.  e.,  excretory  pore;  p.  m.  c.,  primary  mouth  cavity.  X  about  190  times. 
(After  Looss,  1897,  p.  919.  fig.  1.) 

FIG.  33.— Anterior  end  of  a  young  hookworm  (Agchylostoma  duodenale)  during  formation  of  pro- 
visional buccal  capsule:  c.  g.,  cervical  gland;  e.  g.  d.,  dorsal  esophageal  gland;  e.  g.  v.,  ventral 
esophageal  gland;  n.  m.,  new  mouth;  p.,  papillee  on  head;  p.  e.,  excretory  pore;  p.  m.  c.,  primary 
mouth  cavity.  X  578.  (After  Looss,  1897,  p.  920,  fig  2.) 

FIG.  34. — Head  of  larval  hookworm  (Agchylostoma  duodenale)  before  entering  fourth  stage,  five  or  six 
days  after  infection;  n.  m'.,  new  mouth;  p.  c.  m.,  primary  mouth  cavity,  which  extends  through 
the  provisional  buccal  capsule  and  continues  as  lumen  of  the  esophagus.  X  578.  (After  Looss,  1897, 
p.  921,  fig.  3.) 

or  third  day  the  embryo  casts  its  first  skin,  but  does  not  change  its 
organization.  After  about  four  or  five  days  (at  27°  C.)  it  measures 
480  fit  long  by  30  /*  in  diameter. 

Second  stage. — After  the  fifth  day  the  young  worms  begin  to  show 
signs  of  a  second  ecd}^sis,  at  the  same  time  undergoing  certain  other 
changes.  Three  minute  lips,  each  with  two  very  delicate  papillae, 
appear  under  the  skin  at  the  anterior  end;  the  brightly  refringent  cutic- 


27 


ular  lining  of  the  buccal  cavity  and  the  chitinous  teeth  of  the  esopha- 
geal  bull)  disappear;  the  esophagus  elongates,  becomes  thinner,  and  its 
three  divisions  become  less  distinct;  the  tail  becomes  slightly  shorter 
and  more  blunt;  the  anus  lies  90  ^  from  the  tip  of  the  tail.  The  organ- 


FIG.  35.— Young  hookworm  (Agchylostoma  duodenale)  in  fourth  stage,  with  provisional  buccal  capsule: 
c.  <j.,  cervical  gland;  g.,  primordium  of  genital  organs;  n.  $.,  nervous  system;  p.  e.,  excretory  pore. 
X  105.  (After  Looss,  1897,  p.  921,  fig.  4.) 

FIG.  36.— Provisional  buccal  capsule  (fourth  stage)  of  a  larval  hookworm  (Agchylostoma  duodenale), 
about  nine  days  after  infection:  p.  b.  c.,  primordium  of  definite  buccal  capsule.  X  about  420.  (After 
Looss,  1897,  p.  921,  fig.  5.) 

FIG.  37. — Young  male  hookworm  (Agchylostoma  duodenale),  nine  days  after  infection  :  a.,  anus;  c.  g., 
cervical  gland;  g.,  genital  tract;  p.  b.,  primordium  of  bursa  ;  p.  e.,  excretory  canal ;  p.  sp.,  primor- 
dium of  spicules.  X  about  105.  (After  Looss,  1897,  p.  922,  fig.  6.) 

ism  becomes  more  motile,  and  contracts  from  its  outer  skin,  thus  form- 
ing the  stage  (figs.  30-31)  which  has  been  described  as  an  "  encystation," 
but  which  in  reality  is  simply  a  second  ecdysis.  This  is  the  infecting 
stage  of  the  hookworm,  and  ends  the  development  so  far  as  the  free 
life  is  concerned.  No  more  food  is  taken.  In  some  cases,  however, 


28 

the  worm  escapes  from  the  surrounding  cast  skin.  While  water  is 
more  or  less  injurious  to  the  egg  and  the  first  stage,  the  infecting 
" encysted"  stage  exists  well  in  this  medium,  and  Looss  (1897)  suc- 
ceeded in  keeping  these  worms  alive  for  thirty  days  in  water.  Upon 
drying  up  the  larvre  die,  so  that  the  view  that  the  worms  exist  in  dust 
and  are  carried  around  in  the  air,  thus  leading  to  infection,  is  not  well 
founded  (see  p.  30). 

DEVELOPMENT    INSIDE    THE    BODY. 

Upon  being  swallowed  these  young  worms  undergo  further  ecdyses, 
changing  their  internal  organization  at  the  same  time.  We,  may 
recognize,  with  Looss,  a  third  stage,  without  buccal  capsule  (fig.  32); 
a  fourth  stage,  with  a  provisional  buccal  capsule  (fig.  35);  finally,  a 
fifth  stage,  with  the  definite  buccal  capsule,  corresponding  to  the  adult 
form. 

Third  stage  (without  buccal  capsule,  fig.  32). — During  their  free  life 
the  larvae  may  attain  0.65  to  0.7  mm.  in  length  by  25  to  27  V  in  diam- 


38 


FIGS.  38-39.  —  Development  of  definite  buccal  capsule  (38,  011  twelfth  day  after  infection;  39,.  one 
or  two  days  later):  d.  b.  r.,  definite  buccal  capsule;  e.  g.  d.,  dorsal  esophageal  gland;  m.  m.,  margin 
of  definite  mouth  ;  p,  papillae  on  head  ;  p.  b.  c.  d.,  p.  b.  c.  v.,  dorsal  and  ventral  primordia  of  the 
definite  buccal  capsule  ;  p.  t.,  primordium  of  ventral  tooth  ;  t.,  ventral  tooth  ;  the  new  cuticle  can 
be  distinguished  under  the  old.  X  190.  (After  Looss,  1897,  p..923,  figs.  7-8.) 

eter  (at  the  end  of  the  esophagus).  The  esophagus  is  160  ^  long,  and 
its  three  divisions  may  still  be  distinguished.  The  intestine  is  com- 
posed of  about  15  rows  of  two  cells  each. 

Fifteen  hours  after  infection  of  dogs  the  worms  have  passed  below 
the  stomach.  They  now  begin  to  feed,  but  their  growth  is  compara- 
tively slow.  After  about  five  days  they  begin  to  show  signs  of  a 
third  ecdysis,  which  continues  until  about  the  seventh  day.  During 
this  period  important  changes  take  place,  especially  at  the  anterior 
end,  arid  result  in  the  formation  of  the  provisional  buccal  capsule. 

Fourth  stage  (with  provisional  buccal  capsule,  fig.  35).  —  This  is 
the  fourth  larval  stage,  namely,  the  stage  after  the  third  ecdysis.  The 
worms  have  not  increased  notably  in  length,  but  certain  organs  are 
advanced  in  development,  and  the  esophagus  no  longer  shows  its  for- 
mer three  divisions.  The  worms  measure  about  0.66  mm.  long  by  25  /* 
in  diameter,  the  latter  being  nearly  uniform  for  a  greater  part  of  the 


29 

length  (fig.  8;5).  The  provisional  buccal  capsule  attains  40  /*  in  diam- 
eter, and  the  mouth  is  bent  slightly  dorsad.  Two  pairs  of  teeth  are 
visible  at  the  base  of  the  capsule — one  pair  situated  dorsal  ly,  the  other 
ventraljy.  During  this  stage  the  animal  increases  in  length  and  thick- 


-Me... 


FIGS.  40-41. — Male  and  female  hookworms  (Agchylosloma  duodenale)  during  the  fourth  easting  of  skin 
14  to  15  days  after  infection:  a.,  anus;  c.  g.,  cervical  gland;  c.  o.  e.,  cuticle  of  old  esophagus;  c.  *•„ 
cast  skin;  d.  b.  c.,  definite  buccal  capsule;  g.,  genital  organs;  I.  g.,  large  ganglion,  supplying  the 
rays  of  the  bursa;  m.  a.,  anal  muscle;  n.  c.  gl.,  nucleus  of  cervical  gland;  p.  e.,  excretory  pore: 
p.  b.  c.,  provisional  buccal  capsule;  r.  in.  sp.,  retractor  muscles  of  spicules;  sp.,  spicules;  v.,  vulva. 
X  42.  (After  Looss,  1897,  p.  924,  figs.  9-10.) 

ness,  the  inner  organs  become  better  developed,  the  sexes  become 
differentiated,  and  the  definite  buccal  capsule  forms  at  the  anterior 
end.  With  these  changes  the  parasite  prepares  for  its  last — namely, 
a  fourth — ecdysis,  which  occurs  about  fourteen  to  fifteen  days  afte- 
infection. 


30 

Fifth  stage  (with  definite  luccal  capsule). — The  worm  is  now  about 
1.9  (male)  to  2  mm.  (female)  long,  12  to  14  /*  in  diameter — very  much 
smaller  than  the  adult  forms.  It  is  estimated  that  the  parasites 
require  about  four  to  five  or  six  weeks  from  the  time  of  infection  to 
become  mature. 

SOURCE  OF  INFECTION  OF  UNCINARIASIS. 

The  worms  may  be  swallowed  in  contaminated  food  or  in  drinking 
water  during  or  after  the  second  ecdysis.  Persons  handling  dirt  are 
especially  apt  to  get  the  microscopic  worms  on  their  Hands,  and  it  is 
an  easy  matter  to  transfer  them  to  the  mouth,  either  directly  by  biting 
the  finger  nails  or  sucking  the  fingers,  or  indirectly  with  food.  In 
prevention,  therefore,  careful  personal  habits  and  pure  drinking  water 
are  indicated. 

Some  writers  state  that  the  young  stages  are  scattered  in  the  air  by 
the  wind  and  in  a  dry  state,  the  inference  being  that  they  may  then 
be  breathed  in  or  may  contaminate  food.  While  not  caring  to  go  to 
the  extreme  of  stating  that  such  a  method  of  dissemination  or  infection 
is  impossible,  my  own  observations  on  this  class  of  parasites  do  not 
lead  me  to  attach  any  importance  to  aerial  infection.  As  a  rule, 
drying-out  results  in  a  high  mortality  among  nematode  larvae,  embryos, 
and  eggs,  while  moisture,  on  the  other  hand,  is  necessary  for  their 
existence.  Now,  uncinariasis  is  not  so  common  as  to  fill  the  air  with 
dried  larvae,  and  the  chances  of  inhaling  the  latter  appear  to  be  almost 
infinitesimally  small.  Since  the  worms  do  not  increase  in  number  in 
the  intestinal  tract-,  we  should  therefore  expect  (in  case  aerial  infection 
were  common)  to  find  rather  few  cases  of  severe  infection,  but  a  more 
or  less  uniform  light  infection  of  nearly  all  persons  or  animals  inhabit- 
ing an  infected  area,  since  all  are  breathing  the  same  air.  Further,  as 
adults  breathe  more  air  than  children  we  should  expect  the  former  to 
present  the  cases  of  heaviest  infection.  We  should  also  expect  to  find 
the  disease  more  general  in  dry  years  than  in  wet  seasons.  Such,  how- 
ever, does  not  appear  to  be  the  case.  Cases  of  infection  vary  greatlv 
in  intensit}T,  and  the  losses  from  nematode  diseases  in  sheep  are  much 
less  in  dry  years  and  in  dry  localities  than  in  wet  seasons.  As  a 
matter  of  fact,  few  factors  can  be  conceived  of  which  would  probably 
result  in  killing  more  germs  of  the  disease  than  would  dry  winds. 

In  preventing  uncinariasis  and  nematode  diseases  in  general  among 
live  stock,  systematic  draining  and  burning  of  pastures  are  strongly 
advocated. 

Looss  (1898,  1901)  recently  suggested  that  the  larvae  may  enter  the 
human  body  by  way  of  the  skin  and  then  pass  through  the  body  to 
the  intestine.  Startling  as  this  view  is,  Looss  (see  Sandwith,  1902) 
has  recently  demonstrated  the  correctness  of  it.  (See  p.  59.) 


31 
BRIEF  REVIEW  OF  UNCINARIASIS. 

Uncinariasis  is  by  no  means  a  new  disease.  According  to  Sandwith 
(1894),  a  medical  papyrus,  written  about  three  thousand  four  hundred 
and  fifty  j^ears  ago,  embraced  in  an  encyclopedic  form  the  knowledge 
at  that  time  of  Egyptian  teachers.  This  oldest  of  all  books  among 
medical  works  (Eber's  papyrus)  came  into  the  hands  of  Professor 
Ebers  at  Thebes,  in  1873,  and  has  recently  been  translated  into  German. 
Dr.  Joachim  (1890)  and  Scheuthauer  (1881)  agree  that  anemia,  due  to 
hookworms  (Agchylostoma  duodenale),  was  well  known  to  physicians 
of  those  days  under  the  name  of  "  AAA"  and  "  UHA."  The  papyrus 
describes  accurately  among  the  symptoms,  "heart  weakness,  palpita- 
tion, stabbing  cardiac;  pains,  constipation,  edema  of  the  legs,  a  weight 
ih  the  body  pressing  heavily,  and  other  digestive  troubles."  It  further 
prescribes  a  remedy  for  a  patient  who  has  in  his  body  worms,  which 
are  produced  by  the  "  AAA"  disease,  and  possibly  it  is  the  hookworms 
which  are  referred  to. 

Within  modern  times  this  special  form  of  anemia  was  described  in 
Brazil  by  Piso  in  1648;  Labat  (1742  or  1748)  observed  it  in  Guadeloupe, 
Chevalier  (1752)  in  St.  Domingo,  Dazille  and  Bason  (1776)  in  the 
Antilles,  and  Edwards  (1790  or  1793)  in  Jamaica.  In  Europe,  the 
disease  was  first  noted  among  the  miners  of  Anzin  in  1802. 

Not  until  1843  was  the  parasite  (Agchylostoma  duodenale)  described, 
when  Dubini  of  Milan  published  an  account  of  it.  Later  it  was  reported 
from  Egypt,  Germany,  -France,  India,  Ceylon,  Japan,  Australia,  and 
elsewhere,  and  to  it  was  attributed  a  certain  widespread  anemia  of 
brickmakers,  tunnelers  (St.  Gothard  tunnel  anemia),  and  miners. 

Zinn  and  Jacoby  (1898),  who  have  compiled  464  bibliographic  refer- 
ences to  the  disease,  give  two  charts  showing  its  distribution  at  the 
time  their  paper  was  published. 

In  studying  the  maps,  it  will  be  well  to  recall  that  at  the  time  they 
were  printed  nothing  was  known  regarding  the  relations  of  uncinari- 
asis  to  the  soil  (see  p.  47),  hence,  the  areas  which  are  given  as  infected 
are  probably  much  greater  than  the  actual  extent  of  the  infested  terri- 
tory; further,  the  maps  would  indicate  that  they  have  registered  the 
places  in  which  hookworm  disease  has  been  diagnosed,  and  not  neces- 
sarily the  areas  in  which  hookworm  infection  occurs. 

In  connection  with  their  references  to  the  United  States,  they  simply 
mention  Georgia,  Alabama,  and  Louisiana,  saying  that  there  is  little 
to  report  upon  this  subject  for  these  localities. 


32 


BRIEF  REVIEW  OF  UNCINARIASIS  IN  THE  UNITED  STATES. 

In  order  to  understand  the  American  publications  on  this  disease,  it 
must  be  stated  that  much  of  the  so-called  "dirt-eating,"  "pica," 
"cachexia  africana,"  antebellum  "negro  consumption,"  "mal  d'esto- 
mac,"  "malnutrition,"  and  "malarial  anemia,"  described  for  the 
Southern  Atlantic  States,  is  in  reality  due  to  uncinariasis. 

The  earliest  reference  which  seems  quite  positively  to  refer  to  this 
disease  in  this  country,  so  far  as  I  have  yet  found,  is  an  article  by 
Dr.  Pitt  (1808,  pp.  340-341),  who  says  that  along  the  Roanoke  River, 
North  Carolina,  malacia  or  dirt-eating  "prevails  mostly  among  the 
poor  white  people  and  negroes,  and  originates,  in  my  opinion,  from 
a  deficiency  of  nourishment."  Chabert's  (1821)  description  of  the  con- 
ditions of  the  slaves  of  Louisiana,  which  he  attributed  to  dirt-eating, 
Jordan's  (1832,  of  Person  County,  N.  C.)  account  of  "cachexia 
africana,  or  negro  consumption,"  Cotting's  (1836)  account  of  the  dirt- 
eating  in  Richmond  County,  Ga.,  Little's  (1845)  description  of  the 
dirt-eaters  of  Florida,  Le  Conte's  (1845)  account  of  the  dirt-eating  in 
the  pine  barrens  of  Georgia,  Duncan's  (1850)  record  of  dirt-eaters  in 
St.  Mary's  Parish, -La.,  all  apply  so  well  to  the  uncinariasis  I  studied 
in  some  of  the  same  States  that  I  have  no  hesitation  in  assuming  that 
many,  if  not  all,  of  the  cases  were  due  to  infection  with  Uncinaria. 
Lethermann  (Florida),  Lyell  (Georgia  and  Alabama),  and  Heusinger 
and  Geddings  (South  Carolina)  are  said  to  have  published  on  similar 
conditions  in  the  South,  but  not  being  able  to  trace  their  articles,  I 
am  unfortunately  unable  to  give  them  full  credit  for  whatever  views 
they  may  have  advanced. 

Blickhahn  (1893a)  seems  to  have  been  the  first  physician  to  recognize 
as  such  and  to  publish  a  case  of  uncinariasis  for  this  country.  The 
patient  was  a  German  brickmaker  who  had  been  in  the  United  States 
seventeen  months,  and  Blickhahn  believes  the  infection  took  place  in 
Germany.  It  is  true  that  Herff  (1894)  records  a  case  of  supposed 
uncinariasis  observed  in  Texas  in  1864,  and  Allen  J.  Smith  (published 
by  Schaefer,  1901)  found  Uncinaria  eggs  in  feces  of  man  in  Texas  in 
1893,  but  these  publications  are  antedated a  by  Blickhahn's  article; 
hence  Blickhahn  has  priority  of  discovery.  It  is,  however,  interesting 
to  note  that  Blickhahn's  case,  being  in  a  German,  was  probably  caused  by 
the  Old  World  parasite,  Agcliylostoma  duodenale,  while  the  cases  of 
Herff  and  Allen  J.  Smith  were  in  all  probability  the  first  endemic  cases 
recognized.  Herff  did  not  appear  altogether  certain  regarding  his 
diagnosis,  but  his  short  account  of  the  worm  indicates  that  the  inter- 
pretation is  correct. 

« In  all  zoologic  matters  neither  priority  of  observation  nor  priority  of  presentation 
before  a  scientific  society  avails  to  give  priority  of  discovery.  By  international 
agreement,  and  by  custom  extending  back  a  century  and  a  half,  zoologists  recognize 
only  actual  publication  as  governing  a  question  of  this  sort. 


33 

Moehlau  (1896)  reported  five  cases  for  Buffalo,  N.  Y.,  which  were 
supposed  to  be  due  to  the  Old  World  parasite  (Agchylostoma  duodenale). 
Gray  (1901)  recorded  two  cases  for  Richmond,  Va.,  contracted  else- 
where in  the  same  State,  which  he  states  positively  (personal  conver- 
sation) were  due  to  Agchylostoma  duodenale,  and  Tebault  (1899) 
recorded  a  case  of  uncinariasis  in  a  boy  of  German  descent  in  New 
Orleans. 

To  one  of  my  former  pupils,  Dr.  Bailey  K.  Ashford  (1900),  of  the 
U.  S.  Army,  is  unquestionably  due  the  credit  of  having  first  seriously 
.directed  the  attention  of  American  physicians  and  zoologists  to  this 
disease/'  Ashford  in  fact  found  this  malady  very  common  in  Porto 
Rico,  and  although  he  erroneously  considered  the  parasite  to  be  iden- 
tical with  the  Old  World  species,  his  clinical  observations  placed  the 
American  medical  profession  on  its  guard  for  cases  which  might  occur 
in  returning  American  troops. 

In  1901  there  was  a  sudden  increase  in  American  observations. 
Dyer  (March  15,  1901)  reported  a  case  for  St.  Louis.  Schaefer  (May, 
1901)  was  reported  in  the  proceedings  of  the  Texas  Medical  Associa- 
tion (Texas  Medical  News,  May,  1901)  as  presenting  a  paper  on  a  new 
form  of  intestinal  parasite  in  Texas.  The  case  in  question  was  uncina- 
riasis, probably  due  to  Uncinaria  americana,  but  was  not  published  as 
uncinariasis  until  October  26,  1901. 

Claytor's  (June,  1901)  case  is,  so  far  as  I  am  aware,  the  first  pub- 
lished American  case  which  can  be  recognized  as  unquestionably  due 
to  Uncinaria  americana,  although  at  least  some  (and  probably  most,  if 
not  all)  of  Ashford's  cases  were  caused  by  this  species.  Claytor's  case 
was  originally  published  as  an  infection  with  the  Old  World  species, 
Agchylostoma  duodenale  (an  error  for  which  the  responsibility  rests 
upon  me,  not  upon  Dr.  Clay  tor;  the  large-sized  egg  found  should  have 
placed  me  more  on  my  guard). 

Allyn  and  Behrend  (July  13,  1901)  recorded  an  imported  case  in  an 
Italian  boy  in  Philadelphia,  due  apparently  to  Agchylostoma  duodenale, 
and  at  the  same  time  mentioned  three  unpublished  cases  diagnosed  by 
Dr.  L.  Napoleon  Boston,  two  in  1900  and  one  in  1901.  All  three  cases 
came  from  Porto  Rico,  so  that  they  were  probably  due  to  Uncinaria 
americana. 

« It  is  true,  as  has  been  stated,  that  for  some  years  prior  to  Ashford's  publication 
I  had  repeatedly  insisted  upon  the  probability  of  the  frequent  occurrence  of  this 
disease  in  the  United  States,  having  discussed  the  subject  in  my  lectures  on  medical 
zoology  in  the  post-graduate  medical  school  of  the  U.  S.  Army,  and  in  the  medical 
classes  of  Johns  Hopkins  University  and  of  Georgetown  University  (the  latter,  the 
alma  mater  of  Dr.  Ashford),  as  well  as  in  various  medical  meetings;  but  so  far  as  I 
am  aware,  my  views  were  not  printed  until  July,  1901,  so  that  Ashford's  printed 
statements  antedate  mine  by  more  than  a  year.  Furthermore,  his  paper  was  a 
practical  demonstration,  while  my  views  were  theoretical  deductions. 

19558— No.  10—03 3 


34 

In  a  paper  (July,  1901)  written  for  the  Texas  Medical  News  1 
expressed  very  positive  views  to  the  effect  that  uncinariasis  in  man 
must  be  more  or  less  widespread  in  the  United  States,  and  I  discussed 
the  disease  in  general.  The  position  taken  was  based  upon  general 
zoologic  principles,  and,  so  far  as  1  am  aware,  was  the  first  printed 
definite  claim  regarding  the  frequency  or  probable  frequency  of  the 
malady  in  the  United  States. 

Schaefer  (October  26,  1901)  next  published  a  ,case  for  Galveston, 
Tex.,  probably  infected  in  Mexico,  and  made  the  very  important 
statement  that  Allen  J.  Smith  had  found  pne  case  in  Galveston  in 
1893,  and  since  then  that  he  had  encountered  two  [afterwards  six  addi- 
tional] cases  among  some  80-odd  medical  students  of  the  University 
of  Texas. 

The  importance  of  this  discovery  by  Allen  J.  Smith  should  not  be 
underestimated.  To  the  clinician  it  did  not  mean  very  much,  since 
no  record  existed  that  the  students  exhibited  any  very  severe  symp- 
toms. To  the  zoologist,  however,  it  meant  a  practical  demonstration 
that  uncinariasis  was  more  or  less  common  in  the  South.  Here  were 
3  [9]  students  in  a  city  (Galveston);  the  chances  that  the  infection  took 
place  in  Galveston  did  not  seem  very  great;  as  the  students  came  from 
different  places  (according  to  personal  information),  the  infection  must 
be  more  or  less  widespread;  and  since  light  cases  occurred  among 
medical  students,  heavier  infections  must  naturally  occur  among  per- 
sons who  come  more  regularly  in  contact  with  the  dirt.  Allen  J. 
Smith's  observations,  the  importance  of  which  has  not  yet  been  duly 
recognized  by  medical  journals  or  by  his  colleagues,  led  to  some  cor- 
respondence between  himself  and  me,  and  he  very  kindly  forwarded 
specimens  from  one  of  his  cases.  In  some  respects  these  parasites 
resembled  Uncinaria  stenocephala  of  the  dog,  and  both  Allen  J.  Smith 
and  I  were  fully  agreed  that  they  were  not  identical  with  Agchylo- 
stoma  duodenale.  I  obtained  specimens  from  Claytor's  case  and  also 
some  material  which  Ashford  had  sent  from  Porto  Rico  to  the  U.  S. 
Army  Medical  Museum.  All  three  lots  of  worms  agreed  with  each 
other,  and  differed  from  Uncinaria  stenocephala,  which  I  had  obtained 
from  Europe,  as  well  as  from  U.  trigonocephalaa  from  sheep,  U. 
radiata  from  cattle,  U.  Lucasi  from  the  Alaskan  seal,  and  from  every 
other  species  of  Uncinaria  of  which  1  could  obtain  either  specimens 
or  description.  Accordingly,  I  described  (May  10, 1902)  these  worms 
as  a  new  species,  naming  it  Uncinaria  americana. 

Having  now  an  endemic  species,  with  specimens  in  my  possession 
for  Washington,  D.  C.  (patient  came  from  Virginia),  Porto  Rico 
(Ashford's  material),  Cuba  (specimens  sent  by  Guiteras),  and  Galves- 
ton (Allen  J.  Smith's  material),  I  did  not  hesitate  to  state  positively  in 

«  U.  cernua  (Creplin,  1829).     See  Stiles,  1902b,  p.  189. 


35 

a  paper  published  in  the  Eighteenth  Annual  Report  of  the  Bureau  of 
Animal  Industry,  and  issued  on  September  25, 1902,  that  we  must  have 
in  the  United  States  an  endemic  uncinariasis  which  had  been  generally 
overlooked. 

Prior  to  the  appearance  of  the  paper  in  question,  Claude  Smith,  of 
Atlanta,  Ga.  (June,  1902),  had  presented  a  case  of  uncinariasis  before 
the  American  Medical  Association  (see  below,  p.  103),  the  parasite 
afterwards  proving  to  belong  to  the  species  Undnaria  americana. 

H.  F.  Harris  (July  19 ,  1902),  also  published  a  case  of  uncinariasis 
(see  below,  p.  103)  for  Georgia.  In  reply  to  a  letter  from  me,  he  stated 
(August  9)  that  he  had  found  other  cases  also,  and  that  he  was  "  abso- 
lutely sure  this  disease  is  very  common  in  this  [Porter  Springs] 
locality." 

Upon  my  transfer  from  the  United  States  Bureau  of  Animal 
Industry  to  the  United  States  Public  Health  and  Marine-Hospital 
Service,  I  decided  upon  an  early  study  of  uncinariasis  in  man,  to 
determine  its  frequency  and  geographic  distribution  in  the  Southern 
States.  A  preliminary  report  (Stiles,  1902c,  October  24)  was  pub- 
lished, giving  my  results  for  Virginia,  North  Carolina,  and  part  of 
South  Carolina.  This  report  reads  as  follows: 

[Reports  to  the  Surgeon-General  Public  Health  and  Marine- Hospital  Service.] 

HOOKWORM  DISEASE  IN  THE  SOUTH — FREQUENCY  OP  INFECTION  BY  THE  PARASITE 
(UNCINARIA  AMERICANA)  IN  RURAL  DISTRICTS. 

(Preliminary  report  by  Dr.  Ch.  Wardell  Stiles,  chief  of  Division  of  Zoology,  United 
States  Public  Health  and  Marine-Hospital  Service,  detailed  for  this  investigation. ) 

KERSHAW,  S.  C.,  October  22,  1902. 

SIR:  Through  the  director  of  the  Hygienic  Laboratory,  I  have  the  honor  to  submit 
a  brief  preliminary  report  in  regard  to  the  frequency  and  geographic  distribution  of 
hookworm  disease  (uncinariasis)  in  the  Southern  States. 

Meeting  the  disease  in  the  Virgilina  copper-mine  district  of  southern  Virginia  and 
northern  North  Carolina,  I  have  thus  far  traced  it  through  the  coal-mine  district  of 
Cumnock,  N.  C.,  the  brickyards  of  Camden,  S.  C.,  and  the  granite-sand  district  of 
Lancaster  and  Kershaw  counties,  S.  C. 

The  present  indications  are  that  it  is  more  prevalent  in  sandy  regions  than  in  clay 
or  stone  districts.  On  the  farms  and  plantations  of  the  sand  region  of  the  two 
counties  just  mentioned,  it  appears  to  be  the  most  common  disease  of  man,  and  from 
an  economic  point  of  view  it  appears  to  be  of  great  importance.  The  extreme  cases 
seem  to  occur  more  commonly  among  children  and  women  than  among  adult  males 
over  25,  but  the  present  facts  at  my  disposal  do  not  indicate  that  the  malady  is  quite 
so  fatal  as  the  European  form  of  the  disease  caused  by  Undnaria  duodenalis.  All  of 
the  cases  thus  far  examined  are  due  to  Undnaria  americana,  demonstrating  clearly 
that  this  is  an  endemic  infection  and  totally  independent  of  the  cases  which  have 
been  introduced  from  Europe,  Asia,  and  northern  Africa. 

In  general,  it  may  be  said  that  the  "pale  skin,"  the  "heart  disease,"  the 
"diarrhea,"  the  "bloat,"  and  the  suppression  of  menses  which  I  have  thus  far 
examined  all  represented  various  stages  of  heavy  infections  with  Undnaria  americana, 
and  it  is  impossible  to  escape  the  conclusion  that  so  far  as  the  farms  and  plantations 


36 

are  concerned  a  radical  change  in  the  general  therapeutics  practiced  in  the  localities 
in  question  is  urgently  indicated. 

As  for  the  economic  side  of  the  problem,  it  should  he  recalled  that  the  disease  in 
question  is  resulting  in  loss  of  wages,  loss  in  productiveness  of  the  farms,  loss  in 
the  school  attendance  of  the  children,  extra  expenses  for  drugs  and  for  physicians' 
services,  etc. 

The  heavy  and  frequent  infections  found  are  amply  explained  by  the  almost  total 
absence  of  privies  and  closets  on  the  farms  visited.  Defecation  occurs  at  almost  any 
place  within  a  radius  of  50  meters  from  the  house  or  hut,  and  as  a  result  the  prem- 
ises become  heavily  infested  with  the  embryos. 

The  disease  as  thus  far  traced  is  primarily  a  "poor  man's"  malady,  and  in  fre- 
quency it  far  exceeds  even  the  most  extreme  limit  which  theoretical  deductions 
seemed  to  justify  before  commencing  the  field  work.  There  is,  in  fact,  not  the 
slightest  room  for  doubt  that  uncinariasis  is  one  of  the  most  important  and  most 
common  diseases  of  this  part  of  the  South,  especially  on  farms  and  plantations  in 
sandy  districts,  and  indications  are  not  entirely  lacking  that  much  of  the  trouble 
popularly  attributed  to  " dirt-eating,"  "resin-chewing,"  and  even  some  of  the  pro- 
verbial laziness  of  the  poorer  classes  of  the  white  population  are  in  reality  various 
manifestations  of  uncinariasis. 

The  infection  among  the  miners,  so  far  as  discovered,  is  less  severe  and  less  com- 
mon than  the  infection  on  the  farms  and  plantations  of  the  sandy  districts. 
Respectfully, 

CH.  WARDELL  STILES,  Ph.  D., 

Chief  of  Division  of  Zoology. 

On  November  15,  Dr.  H.  F.  Harris,  of  Atlanta,  Ga.,  published  an 
important  notice  regarding  uncinariasis  in  the  South.  After  refer- 
ring to  his  first  case  (see  above,  p.  35),  he  says: 

"  The  discovery  of  a  distinct  American  species  of  the  hookworm  is  very  important, 
as  it  leads  to  the  inference  that  the  aborigines  of  this  country  were  infested  with  this 
parasite,  and  that  the  worm  is  probably  present  in  all  parts  of  the  United  States 
where  the  conditions  are  suitable  for  its  development. 

"My  observations  during  the  last  six  months  bear  out  this  assumption  in  a  most 
striking  manner.  A  few  weeks  after  my  first  case  of  the  disease  was  seen,  a  second 
one  was  encountered  that  originated  in  middle  Georgia,  but  though  I  was  constantly 
on  the  search  for  it  no  other  case  was  found  among  the  numerous  patients  that  come 
to  the  clinics  of  the  Atlanta  College  of  Physicians.  In  June  of  the  present  year  I 
made  a  trip  to  north  Georgia,  a  region  that  has  long  been  noted  as  one  in  which  the 
inhabitants  are  very  pale  and  anseinic,  this  condition  being  commonly  reputed  to  be 
the  result  of  dirt  eating.  Here  I  saw  many  instances  of  what  was  in  all  probability 
ankylostomiasis;  but  as  a  result  of  the  ignorance  of  the  people  and  their  suspicion  of 
all  strangers  a  proper  examination  could  be  obtained  in  only  four  cases,  in  all  of 
which  the  parasite  was  demonstrated.  Subsequently  a  case  of  the  disease  was  seen 
that  originated  in  middle  Alabama.  During  September  and  October  I  have  been 
studying  malaria  in  south  Georgia  and  Florida,  a  region  in  which  the  people  show 
profound  ansemia  even  more  often  than  in  north  Georgia.  This  condition  is  com- 
monly ascribed  to  malaria,  but  my  observations  show  that  in  almost  all  instances  the 
sufferers  have  no  malarial  parasites  in  their  blood,  but  eggs  of  the  ankylostoma  are 
constantly  found  in  the  feces.  During  my  entire  stay  in  this  region  I  only  saw  one 
case  of  profound  ansemia  from  malaria,  and  in  this  instance  the  patient  did  not  exhibit 
the  extraordinary  ansemia  so  commonly  found  in  those  infected  with  the  ankylostoma. 
I  feel  no  hesitation  in  saying  that  time  will  show  that  by  far  the  greater  number  of 
cases  of  ansemia  in  Georgia,  Alabama,  and  Florida  are  due  not  to  malaria  but  to 
the  ankylostoma,  and  that  this  is  the  most  common  of  all  the  serious  diseases  in  this 


37 

region.  There  can  be  no  reasonable  doubt  that  what  is  true  as  regards  the  States 
named  likewise  holds  good  for  the  entire  South.  Since  rny  first  case  was  reported 
13  other  instances  of  the  disease  have  been  seen — 1 1  originating  in  this  State,  and 
1  each  in  Florida  and  Alabama;  and  if  all  of  those  encountered  who  were  suffering 
from  anaemia  could  have  been  examined  there  can  be  no  doubt  that  the  number 
would  be  many  fold  greater. 

"This  communication  is  written  in  the  hope  that  Southern  physicians  will  take  up 
this  most  important  matter  at  once,  for  in  no  other  serious  disease  does  the  victim 
suffer  so  long,  in  no  other  condition  is  he  for  such  a  period  a  menace  to  those  about 
him,  and  in  no  other  malady  of  such  gravity  is  the  treatment  so  rapidly  and  surely 
successful." 

ITINERARY  OF  TRIP  THROUGH   THE   SOUTHERN  ATLANTIC  STATES. 

DISTRICT   OF   COLUMBIA. 

In  September,  1902,  with  the  aid  of  three  assistants  (Messrs.  P.  E. 
Garrison,  B.  H.  Ransom,  and  E.  C.  Stevenson)  I  began  a  systematic 
study  of  animal  parasites  among  the  patients  of  Government  Hospital 
for  the  Insane,  District  of  Columbia.  From  September  10  to  Decem- 
ber 12,  1902,  the  stools  of  500  malea  patients  were  examined  micro- 
scopically and  15  patients,  or  3  per  cent,  were  found  to  be  infected 
with  hookworms.  The  history  has  not  yet  been  examined  for  each 
case,  but  probably  most  of  the  patients  became  infected  in  Cuba, 
Porto  Rico,  or  the  Philippines. 

VIRGINIA. 

Richmond  and  State  farm. — Starting  on  my  field  work,  my  first 
stop  (September  25)  was  Richmond,  Va.  Through  the  courtesy  and 
cooperation  of  DA  Charles  V.  Carrington  I  was  able  to  examine  at 
the  State  penitentiary^  and  the  State  farm  nearly  1,200  convicts.  The 
prisoners  filed  past  Dr.  Carrington  and  myself  in  single  file,  and  we 
selected  those  who  appeared  anemic  or  debilitated.  Those  selected 
were  sent  to  the  hospital  and  kept  there  until  specimens  of  feces  were 
obtained.  In  microscopic  examination  of  6  white  male  convicts  no 
case  of  uncinariasis  was  found.  The  only  zooparasitic  case  noticed 
was  an  exceedingly  heavy  infection  with  whip  worms  (Trichuris 
trichiura)  in  a  man  about  70  years  old. 

In  22  male  negroes  the  examination  was  likewise  negative  so  far  as 
Uncinaria  was  concerned,  but  one  case  of  infection  of  eelworms 
(Ascaris  lumbricoides)  was  found.  In  several  of  the  convicts  starch 
digestion  or  meat  digestion  was  poor,  but  in  most  instances  the  debili- 
tated condition  was  due  to  tuberculosis  or  other  diseases. 

At  the  almshouse  in  Richmond  1  white  female  28  years  of  age  gave 
negative  results;  a  weak-minded  girl  of  7  years  showed  a  heavy 
infection  with  whip  worms  (Trichuris  trichiura).  In  two  negroes  (1 
male,  28  years;  1  female,  30  years)  the  examination  was  negative. 

« In  350  female  patients  examined  to  March  1,  1903,  only  one  case  of  hookworm 
infection  has  been  found. 


38 

It  proved  to  be  so  difficult  to  obtain  specimens  of  feces  from  the 
brickyards  that  no  microscopic  examinations  were  made.  No  clew 
was  obtained  to  any  disease  among  the  workers  which  could  be  inter- 
preted as  probable  uncinariasis. 

Besides  Dr.  Carrington,  I  am  indebted  to  Dr.  Staton  also  for 
cooperation  in  my  work  at  Richmond. 

NORTH    CAROLINA. 

Virgilina  Copper  Mine  district,  southern  Virginia  and  northern 
North  Carolina. — Proceeding  to  the  Virgilina  copper  mine  district  I 
found  it  very  difficult  at  first  to  obtain  specimens  for  examination. 
At  one  mine  1  white  male  and  3  negro  males  were  examined;  all  were 
negative  except  1  negro  22  years  old,  who  showed  infection  with 
Ascaris  lumbricoides.  At  this  mine  defecation  under  ground  is  pro- 
hibited; it  occurs  in  the  surrounding  woods,  at  any  place  within  a 
radius  of  about  50  meters  from  the  shaft. 

At  a  second  mine  three  specimens  of  feces  were  taken  at  random 
from  the  woods;  eggs  of  Uncinaria  americana  were  found  in  one 
specimen,  and  ova  of  Ascaris  lumbricoides  in  a  second.  The  patients 
could  not  be  traced.  Specimens  were  then  obtained  from  4  white  and 
18  negro  miners,  the  feces  being  taken  without  reference  to  the 
physical  condition  of  the  men.  Of  these  22  men,  1  negro  25  years 
old  showed  a  light  infection  with  Uncinaria  americana,  and  inquiry 
developed  the  fact  that  he  uhad  not  been  well  for  some  time."  His 
chief  complaint  had  been  "diarrhea."  In  two  other  cases,  a  white 
man  41  years  old  and  a  negro  34  years  old,  eggs  of  the  eelworm  (Asca- 
ris lumbricoides}  were  found.  At  this  mine  defecation  under  ground 
is  prohibited,  and  a  box  privy  is  located  within  about  50  meters  of 
the  shaft.  The  men  prefer,  however,  to  defecate  in  the  surrounding 
woods. 

1  am  indebted  to  Drs.  F.  D.  Drewry  and  P.  P.  Causey,  and  to  Mr. 
L.  N.  White,  manager  of  the  Person  Consolidated  Copper  and  Gold 
Mines  Compan}^  at  Durgy,  N.  C.,  for  their  kind  cooperation  in  con- 
nection with  my  work  in  Virgilina  and  vicinity. 

Cumnock  Coal  Mines,  Chatham  County. — The  miners  at  this  place 
were  so  suspicious  regarding  my  work  that  it  was  almost  impossible 
to  obtain  specimens  for  examination.  In  fact  only  two  specimens 
could  be  obtained  from  about  40  men.  One  of  these,  a  white  miner, 
52  years  of  age,  and  in  rather  anemic  condition,  showed  infection  with 
Uncinaria  americana.  The  other,  a  white  engineer,  34  years  old, 
gave  negative  results. 

Sanford,  Moore  County. — Specimens  from  4  whites  (2  males,  and  2 
females),  obtained  by  2  of  the  local  physicians,  were  examined  with 
negative  results. 


39 

SOUTH   CAROLINA. 

Camden,  Camden  County.—  Unexpectedly  delayed  at  Camden,  I 
visited  the  brickyards  with  Dr.  J.  W.  Corbett.  Of  7  specimens  of 
feces  picked  up  at  random  from  the  ground,  probably  most  if  not  all 
from  negroes,  1  was  found  infected  with  Uncinaria  americana.  One 
white  laborer  also  showed  infection  with  the  same  parasite. 

Haile  Goldmine,  Lancaster  County. — Through  the  kindness  of  Cap- 
tain Thiess,  the  superintendent  of  the  mines,  and  Dr.  Gregory,  the 
local  physician,  I  was  able  to  examine  specimens  from  5  white  men 
and  5  negroes  connected  with  the  mine.  All  of  these  examinations 
were  negative. 

Upon  leaving  Richmond  I  happened  to  recall  the  observation  made 
by  Lucas  (in  Jordan  &  Clark,  1898,  p.  TO)  in  connection  with  uncina- 
riasis  of  the  seal  pups  of  Alaska,  namely,  that  the  infected  animals 
were  almost  invariably  found  on  the  sand  rookeries;  I  also  recalled 
that  I  had  observed  severe  outbreaks  of  uncinariasis  in  sheep  and 
goats  on  more  or  less  sandy  pastures,  and  further  that  a  severe  out- 
break of  the  same  disease  among  dogs  had  once  been  reported  to 
me  as  occurring  in  a  sandy  yard.  Not  recalling  at  the  time  any 
similar  observation  for  uncinariasis  in  man,  I  determined  to  test  the 
subject  at  the  first  opportunity,  and  from  Richmond  to  Haile  Gold- 
mine I  had  diligently  inquired  of  every  physician  1  met,  whether  he 
found  more  anemia  on  sand,  clay,  or  rock  soil.  Most  physicians 
replied  that  they  had  paid  no  attention  to  the  subject;  one  physician 
stated  that  he  thought  anemia  was  more  common  in  sandy  than  in 
clay  localities. 

Through  Captain  Thiess  I  learned  that  the  land  near  the  mines  was 
chiefly  a  granite  sand.  With  Dr.  Gregory,  I  drove  about  4  miles 
into  the  sandy  district  in  Lancaster  County  and  found  a  family  of  11 
members,  one  of  whom  was  an  alleged  ' ;  dirt-eater. "  The  instant  I 
saw  these  11  persons  I  recalled  Little's  (1845)  description  of  the  dirt- 
eaters  of  Florida.  (See  Stiles,  1902b,  p.  208.)  A  physical  examina- 
tion made  it  probable  that  we  had  before  us  11  cases  of  uncinariasis, 
and  a  specimen  of  feces  from  one  of  the  children  gave  the  positive 
diagnosis  of  infection  with  Uncinaria  americana.  There  were  hun- 
dreds of  eggs  present. 

Inquiring  for  the  largest  plantation  of  this  sand  district,  I  was 
directed  to  a  place  in  Kershaw  County,  about  6  miles  from  Kershaw, 
and  through  the  kindness  of  Dr.  Twitty  and  the  owner  of  the  planta- 
tion, I  was  able  to  make  the  desired  examinations.  , 

There  are  about  60  white  "hands"  on  this  farm.  Going  to  a 
field  I  found  about  20  at  work.  These  20  persons,  men,  women,  and 
children,  corresponded  in  more  or  less  detail  to  the  description  of 
the  so-called  dirt-eaters  and  resin-chewers.  A  physical  examination 


40 

showed  that  they  also  corresponded  to  cases  of  uncinariasis.  A  family 
of  10  members  was  selected  and  examined  carefully.  Specimens  of 
feces  from  4  of  them  were  examined  microscopically  and  found  to 
contain  hundreds  of  eggs  of  Uncinaria  americana.  The  owner  of  the 
plantation  informed  me  that  it  would  be  a  waste  of  my  time  to  exam- 
ine the  remaining  40  "'hands,"  as  they  were  in  exactly  the  same  con- 
dition as  the  20  already  examined. 

Driving  to  a  neighboring  farmhouse,  1  found  a  family  of  5  members, 
3  of  whom  presented  such  severe  and  typical  symptoms  that  I  had  no 
hesitation  in  diagnosing  them  as  due  to  uncinariasis. 

Kershaw  County. — While  driving  back  to  Kershaw,  I  passed  a 
country  schoolhouse.  The  children,  about  twenty-five  or  thirty  in 
number,  were  at  play  during  recess,  and  a  mere  glance  at  them  was 
sufficient  to  show  that  30  to  40  per  cent  presented  the  same  general 
appearance  as  the  children  on  the  neighboring  plantation. 

At  Kershaw  several  extreme  cases  were  met  on  the  street.  The 
persons  in  question  had  come  in  from  the  country.  One  farmer,  living 
about  9  miles  away  from  Kershaw,  had  with  him  two  of  his  children. 
He  stated  that  his  entire  family,  10  in  number,  had  suffered  or  were 
suffering  in  the  same  way  as  these  two  boys.  Physical  examination 
made  uncinariasis  probable,  and  the  microscopic  examination  of  the 
feces  showed  heavy  infections  with  Uncinaria  americana. 

Inquiry  among  the  local  physicians  and  the  more  intelligent  laity 
elicited  the  information  that  the  cases  that  1  had  seen  represented 
conditions  which  were  usually  attributed  to  "dirt-eating,"  "resin- 
chewing,"  "heart  disease,"  "bloat,"  "amenorrhea,"  "anemia  due  to 
malaria"  (mosquitoes  were  noticeable  chiefly  by  their  absence), 
"general  debility,"  "poor  nourishment,"  etc.  1  was  further 
assured  that  these  conditions  were  general  throughout  this  region,  and 
were  not,  or  only  slightly,  amenable  to  treatment. 

Taking  these  cases  together,  some  forty  or  fifty  in  all,  which  I 
examined  carefully  within  three  days,  we  have  one  common  symptom, 
namely,  anemia;  nearly  all  other  s}^mptoms  noticed  could  be  reduced 
to  sequelae  of  anemia;  further,  in  every  case  examined  microscopically, 
exceedingly  heavy  infections  with  Uncinaria  americana  were  found. 
Under  these  conditions,  and  because  the  general  clinical  history  corre- 
sponded so  well  with  uncinariasis,  I  have  not  the  slightest  hesitation 
in  grouping  the  cases  observed  as  due  to  Uncinaria  americana. 

Charleston,  Charleston  County. — Through  the  kindness  of  Drs.  John 
Dawson  and  Robert  Wilson,  jr.,  I  was  able  to  meet  the  students  of 
the  Charleston  Medical  College.  Explaining  the  object  of  my  trip,  I 
asked  for  volunteers  to  submit  to  microscopic  examination.  Sixteen 
of  the  students  and  1  member  of  the  faculty  immediately  volun- 
teered. Of  these  IT  men  (all  white,  of  course),  4  were  found  infected 
with  Uncinaria  americana  and  1  showed  a  heavy  infection  with 


41 

Hymenolepis  nana.  The  cases  of  uncinariasis  came  from  the  sand  dis- 
tricts— namely,  Barn  well  County;  Florence,  Saint  John  County;  a 
sea-coast  island  near  Charleston,  and  Edisto  Island,  Charleston  County. 

Through  the  courtesy  of  Dr.  Huger  and  the  ladies  in  charge  of  the 
Charleston  Orphan  Asylum,  I  was  able  to  examine  230  white  children, 
both  boys  and  girls.  I  picked  out  20  for  closer  examination,  because 
of  the  anemic  condition,  or  stunted  growth,  etc.  Of  the  fecal  speci- 
mens obtained,  15  showed  infection  with  Uncinaria  americana.  All 
of  the  children  came  from  sandy  districts  of  the  State— namely,  Sum- 
merville,  Dorchester  County;  Berkeley  County;  Adams  Run,  Colleton 
Count}7;  Plum  Island,  Charleston  County,  and  McClellanville,  Charles- 
ton County.  One  additional  case  failed  to  show  eggs  in  the  feces,  but 
the  clinical  history  during  early  childhood  seemed  typical  for  uncina- 
riasis (see  p.  58,  case  of  L.  B.).  Of  the  4  remaining  cases  (2  from 
Charleston  (city)  and  2  from  Edgeville),  1  Charleston  boy  Hi  years 
old  and  1  Edgeville  boy  11  }rears  old  showed  infection  with  whip 
worms  (Trichuris  trichiurd). 

Besides  the  Charleston  physicians  mentioned  above,  I  am  indebted 
to  Dr.  Grange  Simons,  president  of  the  State  board  of  health;  Dr.  J. 
Mercier  Green,  city  health  officer,  and  several  other  gentlemen,  for 
their  kind  cooperation  in  my  work.  Dr.  De  Saussure  stated  to  me 
that  he  had  found  the  eggs  of  Uncinaria  in  the  stools  of  several 

patients. 

GEORGIA. 

Atlanta,  Fulton  County. — Learning  incidentally  that  Drs.  Claude  A. 
Smith  and  H.  F.  Harris  were  continuing  their  studies  on  uncinariasis 
in  Atlanta,  I  left  the  city  without  seeing  any  cases  personally.  No 
reason  was  apparent  which  made  it  necessary  to  confirm  their  work 
for  this  locality,  and,  furthermore,  the  territory  belonged  to  them  as 
local  men  who  were  carrying  on  their  investigations  at  their  own 
expense. 

In  connection  with  northern  Georgia  it  may,  however,  be  stated  that 
according  to  Dr.  Lamartine  G.  Hardman,  a  member  of  the  Georgia  leg- 
islature, a  condition  exists  in  Jackson  County,  Ga. ,  which  corresponds 
to  what  I  found  in  Kershaw  and  Lancaster  counties,  S.  C. 

Macon,  JSM  County. — Through  the  kindness  of  the  local  physicians 

1  was  able  to  examine  two  white  orphan  asylums  in  Macon. 

In  one  of  these,  Dr.  Clark  (consulting  physician)  and  I  selected  from 
among  the  85  children  17  boys  and  girls  for  closer  examination.  The 
selection  was  made  in  the  same  manner  as  at  Charleston,  namely, 
because  of  the  pale,  weak,  or  otherwise  poor  condition".  Microscopic 
examination  showed  12  cases  of  infection  with  Uncinaria  americana, 

2  cases  of  infection  with  Hymenolepis  nana,  and  3  negative  cases.     The 
uncinariasis  cases  came  from  sandy  districts,  namely:  Americus,  Sum- 
ter  County,  1;  Buena  Vista,  Marion  County,  2;  Thomasville,  Thomas 


42 

County,  1;  Savannah,  Chatham  County,  1;  and  Waycross,  Ware 
County,  Ga.,  1;  and  Wacissa,  Jefferson  Count}7,  1;  De  Land,  Volusia 
County ,  4;  and  Liveoak,  Suwanee  County,  Fla.,  1.  Both  Ilymonelepis 
cases  came  from  Georgia. 

At  another  orphan  asylum,  through  the  kindness  of  Dr.  Little,  the 
consulting  physician,  I  examined  112  white  children,  all  from  Georgia. 
I  selected  21  for  closer  study,  and  the  microscopic  examination  of  the 
feces  revealed  17  cases  of  infection  with  Uncinaria  americana,  1  light 
infection  with  Hymenolepis  nana,  and  2  negative  cases,  1  of  which  was 
doubtless  malarial.  The  17  cases  came  from  the  following  places: 
Baxley,  Appling  County,  1;  Cordele,  Dooly  County,  1;  Darien, 
Mclntosh  County,  1;  Effingham  County,!;  Johnson  County,  1;  Jones 
County,  4;  Kinderlou  Station,  Lowndes  County,  1;  Lyon,  Tattnall 
Count}7,  1;  Monroe  County,  1;  Richwood,  Dooly  County,  2;  Sanders- 
ville,  Washington  County,  1;  Waycross,  Ware  County,  2. 

Four  cotton  mills  were  next  inspected,  some  of  the  houses  of  the 
factory  hands  were  visited,  and  about  25  or  30  cases  of  uncinariasis 
were  found.  Inquiry  developed  the  important  facts  that  the  infected 
persons  had  come  to  the  mills  from  the  rural  sand  districts,  and  that 
in  general  their  condition  improved  with  their  residence  in  the  city. 
An  examination  of  the  premises,  both  of  the  mills  and  of  the  houses, 
did  not  indicate  that  the  disease  would  spread. 

At  a  negro  school  in  Macon  I  failed  to  find  a  single  case  of  uncinari- 
asis .which  could  be  diagnosed  symptomatically  with  even  a  semblance 
of  confidence.  In  one  case  only  did  I  even  suspect  the  disease. 

"  Circus  day  "  brought  thousands  of  people  into  view  on  the  streets, 
many  coming  in  from  the  surrounding  country.  Several  cases  of 
probable  uncinariasis  were  observed  among  the  whites,  but  none 
among  the  negroes. 

Besides  the  Macon  physicians  mentioned  above  in  connection  with 
the  orphan  asylums,  I  am  under  obligations  to  Dr.  A.  M.  Burt,  and 
especially  to  Dr.  H.  McHatton  for  their  cooperation  in  my  work. 

Milledgeville,  Baldwin  County. — Through  the  kindness  of  Dr.  T.  O. 
Powell,  superintendent,  and  Dr.  M.  L.  Perry,  pathologist,  of  the 
State  sanitarium,  I  was  able  to  see  a  large  number  of  the  patients. 
Extreme  cases  of  anemia  were  conspicuous  by  their  absence.  Two 
patients  were  selected  as  possible  cases  of  uncinariasis,  the  micro- 
scopic examination  being  left  in  the  hands  of  Dr.  Perr}7,  who  has 
kindly  written  me  that  it  was  negative. 

Fort  Valley,  Houston  County. — With  the  cooperation  of  Dr.  M.  S. 
Brown,  a  local  physician,  I  found  about  10  cases  of  uncinariasis  near 
town  within  an  hour's  time.  The  clinical  histories  were  so  typical 
that  it  was  considered  scarcely  necessary  to  make  a  microscopic  exam- 
ination; nevertheless  this  was  done  in  one  case  with  the  result  of 
finding  a  severe  infection  with  Uncinaria  americana.  After  seeing 
the  class  of  cases  I  desired  to  find,  Dr.  Brown  assured  me  that  they 


43 

were  common  in  that  region,  and  that  he  could  easily  find  50  or 
more  cases  within  a  day's  time. 

Albany •,  Dougherty  County. — Leaving  the  sand  district  I  next  visited 
Albany,  which  is  surrounded  by  c\&y.  Corresponding  to  the  change 
in  the  soil  there  was  a  change  in  the  medical  facies.  Uncinariasis 
disappeared,  except  for  cases  which  came  in  from  the  neighboring 
sand  districts,  while  malaria  increased.  Dr.  Hilsman,  one  of  the  local 
physicians,  kindly  drove  around  with  me  to  find  cases,  but  we  were 
obliged  to  go  about  15  kilometers  (9  miles),  namely^  into  Lee  County, 
before  we  located  a  family  with  uncinariasis.  During  this  drive  we 
left  the  clay  soil  and  passed  into  a  sand  district,  with  pine  woods. 
The  family  in  question  presented  four  typical  extreme  cases;  although 
microscopic  examination  for  sake  of  diagnosis  seemed  unnecessary  it 
was  nevertheless  made  and  showed  heavy  infection  with  Uncinaria 
americcma. 

While  with  Dr.  Hilsman  in  Albany  I  made  a  most  fortunate  mistake 
in  diagnosis.  The  patient  was  a  boy  about  13  or  14  years  old.  He 
had  a  clear  case  of  malaria  (typical  history,  enlarged  spleen,  etc.),  but 
in  addition  to  that  I  was  confident  that  he  had  a  medium  or  light 
infection  with  uncinariasis.  Microscopic  examination  proved  me  in 
error.  This  boy  lived  in  a  clay  district  and  had  never  lived  in  sand; 
furthermore,  he  did  not  show  the  eye  symptom,  which  I  shall  discuss 
later  (see  p.  65).  This  is  the  last  time  I  attempted  a  definite  diagnosis 
upon  symptoms  of  any  medium  or  light  case  unless  severe  cases 
occurred  in  the  same  family. 

As  soon  as  Dr.  Hilsman  understood  the  kind  of  cases  I  desired  to 
see  he  stated,  with  the  utmost  positiveness,  that  they  did  not  arise  in 
and  around  Albany  until  the  sandy  soil  was  reached.  Occasionally 
cases  came  to  Albany  from  the  neighboring  sand  counties,  but  the 
local  anemia  Dr.  Hilsman  considered  to  be  almost  entirely  of  malarial 
origin — an  opinion  in  which  I  can  only  concur  after  what  I  saw  in 
that  city. 

I  happened  to  be  in  Albany  on  Saturday,  when  the  country  folks  for 
miles  around  come  to  town.  Standing  on  the  street  corner  for  several 
hours,  I  must  have  seen  about  200  whites  and  fully  3,000  negroes  who 
drove  or  walked  into  town.  Of  the  whites,  I  noticed  about  5  cases  of 
probable  uncinariasis.  Two  of  the  cases,  whom  I  was  able  to  inter- 
rogate, gave  a  typical  history  of  uncinariasis  extending  back  for  several 
years,  but  no  history  of  malaria.  They  came  from  neighboring  sand 
counties.  Among  the  3,000  negro  men,  women,  and  children,  whom 
I  saw,  there  was  only  one  person  in  whom  1  even  suspected  from  his 
general  appearance  that  uncinariasis  might  be  present. 

WillacoocJiee,  Coffee  County. — In  southern  Georgia,  Coffee  County 
bears  the  reputation  of  being  more  or  less  a  center  for  dirt-eaters.  It 
is  a  sandy,  pine-wood  district,  with  numerous  swamps,  which  indicate 
a  more  impervious  subsoil.  As  a  result,  both  malaria  and  uncinariasis 


44 

were  found,  and  it  was  exceedingly  interesting  to  note  the  ease  with 
which  an  error  in  diagnosis  in  medium  and  light  cases  could  be  made 
if  the  microscope  were  not  used.  Extreme  cases,  however,  could  be 
easily  distinguished  without  the  microscope.  Several  cases  of  typical 
extreme  uncinariasis  were  seen  on  the  street,  but  not  examined  care- 
fully. Then,  through  the  kindness  of  Dr.  Wilcox,  I  was  able  to  make 
a  careful  examination,  both  physical  and  microscopic,  of  a  group  of  8 
cases  at  the  sawmills  a  short  distance  from  town.  After  Dr.  Wilcox 
examined  these  cases  with  me,  he  declared  that  he  knew  of  at  least  200 
similar  patients  within  the  territory  of  his  practice.  He  considered 
this  condition  one  of  the  most  common  diseases  of  that  region,  but 
thought  malaria  was  fully  as  common  if  not  more  so. 

Way  cross,  Ware  Comity. — Passing  now  to  Way  cross,  I  entered  a  dis- 
trict where  uncinariasis  is  exceedingly  common.  Drs.  R.  P.  Izlar  and 
J.  L.  Walker  assured  me  that  the  cases  I  was  tracing,  two  of  which 
1  saw  with  Dr.  Walker,  were  much  more  common  than  was  malaria, 
the  proportion  being  about  20  to  1.  In  this  district  these  patients  are 
called  "Branch- water  people."  Both  Dr.  Izlar  and  Dr.  Walker  stated 
that  they  could  easily  show  me  scores  of  cases  within  a  radius  of  a  few 
miles. 

FLORIDA. 

Jacksonville,  Duval  County. — In  Jacksonville  two  cases  of  typical 
uncinariasis  were  seen  on  the  street.  One  of  these  patients  was  traced 
to  the  county  in  which  the  boy  had  formerly  lived. 

Both  the  State  and  the  city  health  offices  assured  me  that  the  condition 
I  was  hunting  was  perfectly  familiar  to  them — that  it  was  prevalent 
throughout  the  State,  especially  in  the  "flat-woods  district,"  and  that 
Florida  physicians  interpreted  it  as  an  anemia  due  to  malaria  and 
improper  diet. 

Waldo,  Alachua  County.  —Through  the  kindness  of  the  local  phy- 
sician, Dr.  J.  W.  Boring,  1  was  able  to  examine  two  groups  of  typical 
cases  of  uncinariasis  within  a  short  distance  from  town.  Dr.  Boring 
assured  me  that  this  condition  was  exceeding  common  in  Florida  and 
was  generally  interpreted  as  an  anemia  due  to  malaria  and  improper 
diet. 

Ocala,  Marion  County. — In  Ocala  I  saw  several  typical  cases  of 
uncinariasis  on  the  street,  and,  through  the  kindness  of  Dr.  A.  L.  Izlar, 
I  was  able  to  examine  5  positive  cases  and  1  probable  case  more 
closely.  Dr.  Izlar  confirmed  the  statements  of  the  health  offices  in 
Jacksonville,  Fla.,  relative  to  the  frequency  and  interpretation  of  the 
disease. 

From  Ocala  I  returned  (November  16)  directly  to  Washington,  D.  C. , 
and  noticed  several  cases  which  presented  the  appearance  I  had  found 
typical  of  uncinariasis,  as  the  train  stopped  at  various  stations  in 
Florida. 


45 


SYMPTOMATOLOGY  OF  UNCINAIUASIS.« 

In  connection  with  the  symptoms,  let  us  recall  that  uncinariasis  is 
caused  by  hookworms  about  half  an  inch  long  which  live  in  the  small 
intestine  for  several  meters  below  the  stomach. 

These  worms  fasten  to  the  mucosa  and  suck  blood.  They  lay 
numerous  eggs,  which  can  be  found  by  a  microscopic  examination  of 
the  stools.  The  number  of  eggs  in  the  feces  and,  in  a  general  way 
also,  the  severity  of  the  symptoms  will  vary  with  the  number  of  para- 
sites present  and  with  the  duration  of  the  infection. 

The  injury  to  the  patients  results  from  the  following  factors:  (1) 
Sucking  of  blood  by  the  parasites,  which  is  a  constant  drain  on  the 
system;  (2)  loss  of  blood  into  the  intestine  through  the  minute  wounds 
made  by  the  parasite,  a  factor  which  also  tends  to  deplete  the  system; 
(3)  the  wounds  form  points  of  attack  for  bacteria,  hence  increase  the 
chances  of  bacterial  infection  as  well  as  of  toxic  infection  from  partly 
digested  and  decomposed  food;  (4)  the  wall  of  the  duodenum  and 
jejunum  becomes  thickened  and  degenerated,  and  its  function  is  thus 
decidedly  interfered  with;  (5)  the  parasites  in  all  probability  produce 
a  poisonous  substance  which  acts  upon  the  patient. 

Theoretically  there  is  only  one  sign  which  is  present  in  every  case, 
namely,  the  presence  of  one  or  more  parasites  in  the  intestine.  If 

a  This  discussion  of  symptoms  will  be  influenced  to  no  slight  degree  by  the  fact 
that  during  my  trip  my  associates  have  been  almost  entirely  practicing  physicians, 
particularly  in  rural  districts,  rather  than  laboratory  specialists;  and,  since  it  is  more 
particularly  the  country  practitioner  whom  I  desire,  to  reach  by  this  paper,  I  shall 
not  hesitate  to  use  vernacular  names  even  if  these  do  not  invariably  have  a  classical 
origin. 

My  trip  was  undertaken  in  order  to  prove  the  frequency  and  geographic  distribu- 
tion of  the  parasite,  not  to  study  the  symptoms  it  causes.  It  was  therefore  a  zoologi- 
cal, not  a  clinical,  trip,  and  on  this  account  a  zoologist,  not  a  clinician,  undertook  the 
investigation.  Not  posing  in  any  sense  of  the  term  as  a  clinician,  I  feel  that  any 
observations  which  I  have  made  upon  symptoms,  sensu  stricto,  should  be  looked 
upon  as  over  and  above  the  amount  of  work  which  should  be  justly  expected  of  me. 
Certain  symptoms  I  could  not  help  noticing.  The  circumstances  of  my  trip,  the 
rapid  travel,  short  stops,  and  the  fact  that  the  work  was  done  among  strangers,  and 
usually  in  the  field  instead  of  in  a  hospital,  absolutely  excluded  certain  observations, 
even  had  I  considered  that  I  was  the  proper  person  to  make  them. 

If,  therefore,  the  reader  misses  in  this  discussion  observations  on  any  particular 
symptom  in  which  he  is  especially  interested,  I  beg  that  he  wyill  recall  that  it  is  self- 
understood  that  the  finer  points  in  symptomatology  must  be  studied  by  expert 
clinicians. 

I  regret  that  it  is  not  feasible  for  me  at  the  present  time  to  review  the  entire  medi- 
cal literature  on  uncinariasis.  Such  an  undertaking  would  involve  an  unjustifiable 
delay  in  sending  much-needed  information  to  physicians  in  the  infected  district. 

In  connection  with  my  own  observations,  however,  I  shall  make  frequent  refer- 
ences to  the  noted  paper  entitled  "Observations  on  400  cases  of  anchylostomiasis," 
published  in  1894  by  F.  M.  Sandwith,  M.  D..  physician  to  the  Kasr-el-aini  Hospital. 
Cairo,  Egypt,  thus  supplementing  my  description  with  the  views  expressed  by  a 
trained  clinician. 


46 

these  worms  are  in  an  egg-laying  stage  ova  will  be  found  in  the 
feces.  But  from  a  practical  standpoint,  severe  cases  present  what 
seems  to  be  a  characteristic  type,  and  even  medium  cases  often  present 
a  more  or  less  typical  clinical  history. 

The  statement  is  not  infrequently  made  that  there  is  one  way  and 
only  one  way  to  diagnose  a  case  of  uncinariasis,  namely,  by  examina- 
tion of  the  stools  to  find  the  parasites  or  their  eggs. 

Academically  this  statement  is  more  or  less  correct,  yet  practically 


FIG.  42.— A  severe  case  of  hookworm  disease  observed  in  Florida.  Note  the  bloated  face,  the  drooping 
shoulders,  the  prominent  abdomen,  and  the  thin  arms  and  legs.  This  girl  is  about  fifteen  years 
old.  Original,  from  a  kodak  photograph. 

it  should  be  somewhat  modified.  Sandwith  (1894,  p.  13),  to  quote 
from  a  clinician,  states  that  "fades  of  the  patient  is  characteristic, 
though  it  is  difficult  to  describe  his  discontented,  harassed  expression, 
which  sometimes  changes  to  a  ready  smile  after  a  month's  stay  in  a 
hospital. "  The  data  at  my  disposal  would  lead  me  to  divide  the  cases 
of  hookworm  disease  I  have  observed  into  three  general  but  not  very 
sharply  defined  classes,  namely: 

(1)  Light  cases,   including  those   in  which   practically  no   distinct 
symptoms  of  the  disease  are  noticed,  but  in  which  a  few  hookworm 


47 

eggs  are  discovered  in  the  stools.  We  may  also  place  here  a  number 
of  cases  in  which,  in  addition  to  the  presence  of  eggs,  there  is  a  slight 
diarrhea  or  some  other  slight  symptom,  including  more  or  less  rapid 
exhaustion  after  physical  exertion,  hence  an  indisposition  to  work, 
which  is  usually  interpreted  as  laziness.  Cases  of  this  class  are  found 
in  the  infected  areas  and  elsewhere,  since  infected  people  may  move 
away  from  the  sand  districts. 

(2)  Medium  cases,  including  those  in  which  the  disease  has  progressed 
to  such  an  extent  that  a  more  or  less  anemic  condition  is  noticed,  but 
other  symptoms  are  not  especially  marked.     If  these  patients  were 
found  outside  the  infected  area,  the  diagnostician  (especially  if  he  is 
not  familiar  with  the  disease)  would  probably  not  see  anything  par- 
ticularly characteristic  in  them;  many  of  these  cases,  however,  show 
a  more  or  less  typical  history,  and  if  a  history  of  residence  upon 
sandy  soil  in  tropical  or  subtropical  regions  can  be  obtained,  uncina- 
riasis  should  certainly  be  strongly  suspected.     If  these  cases  occur  in 
a  family  which  also  presents  severe  cases  of  uncinariasis,  the  diagnosis 
of  hookworm  disease  in  the  medium  cases  is  usually  quite  safe,  even 
if  a  microscopic  examination  is  not  undertaken. 

(3)  Severe  cases,  in  which  we  find  that  striking  set  of  symptoms 
which   even  the   laity   in   our  Southern  States  attributes  to  "dirt- 
eating."     These  patients  present  a  facies  which  is  well  recognized  by 
Southern  physicians.     If  the  patient  is  found  in  a  Southern  sand  area, 
the  diagnosis  is  practically  certain.     If  found  outside  of  the  infected 
area,  with  a  history  of  previous  residence  in  a  Southern  sand  district, 
its  recognition  symptomatically  ought  not  to  be  attended  with  diffi- 
culty.    In  case  of  doubt,  if  a  microscope  is  at  hand,  the  test  may  be 
made  in  less  than  five  minutes;  if  no  microscope  is  at  hand,  the  blot- 
ting paper  test  (see  p.  81)  will  usually  suffice. 

Turning  now  to  an  analysis  of  symptoms,  I  will  give  my  observa- 
tions on  the  severe  cases.  It  is  needless  to  state  that  the  symptoms 
discussed  may  vary  in  intensity,  and  that  not  every  symptom  men- 
tioned is  found  in  every  severe  case.  We  find  on  the  contrary  an 
imperceptible  gradation  between  the  severest  and  the  lightest  cases. 

GENERAL    PREDISPOSING    FACTORS. 

INFECTION   OCCURS   CHIEFLY   ON   SANDY    SOIL. 

In  connection  with  the  clinical  history,  the  residence  on  sandy  soil 
is  undoubtedly  one  of  the  most  important  points  to  be  obtained.  If 
an  anemic  patient  gives  no  history  of  temporary  or  permanent  resi- 
dence on  a  sandy  soil,  uncinariasis  is  not  absolutely  excluded,  but 
according  to  my  experience  the  chances  are  against  it.  If  on  the 
other  hand  a  history  of  sojourn  or  residence  in  a  sandy  rural  district 
is  obtained,  the  probabilities  of  uncinariasis  are  decidedly  increased. 


48 

Nearly  every  case  of  the  disease  found  during  the  entire  trip  was 
either  living  at  the  time  in  a  sandy  district  or  had  lived  in  such  a  place 
a  few  years  previously.  As  soon  as  I  entered  the  sandy  areas,  uncina- 
riasis  was  found.  As  soon  as  I  left  the  sand,  as  at  Albany,  local  foci 
of  infection  of  uncinariasis  disappeared. 

Inquiry  among  physicians  at  first  failed  to  elicit  any  definite  state- 
ment regarding  the  soil  on  which  anemia  was  most  frequent,  but  upon 
going  farther  south  several  physicians  were  met  whose  experience 
fully  confirmed  my  observations  on  this  point.  One  physician  in  par- 
ticular, Dr.  A.  M.  Burt,  of  Macon,  was  of  the  emphatic  opinion  that 
in  bringing  the  condition  which  1  have  interpreted  as  uncinariasis  into 
connection  with  the  sandy  soil,  I  had  found  the  keynote  to  the  distri- 
bution of  the  entire  disease.  Dr.  McHatton,  of  Macon,  called  my 
attention  to  the  fact  that  in  antebellum  days  the  slave  owners  in  the 
Lower  Mississippi  Valley  frequently  provided  special  quarters,  which 
were  removed  from  the  sand  districts,  and  to  which  they  sent  the 
dirt-eating  and  other  sick  negroes  and  also  negresses  about  to  be  con- 
fined, the  view  being  held  that  a  clay  soil  was  more  salubrious  than  a 
sandy  soil.  This  view,  in  fact,  I  found  to  be  rather  prevalent  among 
the  farm  hands.  Time  after  time  they  remarked,  "  We  were  never  sick 
so  long  as  we  lived  in  a  clay  district,"  "This  disease  developed  after 
we  moved  upon  sand,"  etc. 

This  view  that  uncinariasis  follows  the  sand  is  supported  by  evi- 
dence obtained  in  Alaska  by  Mr.  F.  A.  Lucas.  After  the  discovery 
was  made  that  uncinariasis,  caused  by  Uncinaria  Lucasi,  was  preva- 
lent among  the  seal  pups,  Lucas  (see  above,  p.  39)  showed  that  it  was 
practically  only  the  seals  on  the  sandy  rookeries  which  were  infested 
with  the  parasites. 

As  stated  above  (p.  39),  I  have  also  observed  two  outbreaks  of 
uncinariasis  among  sheep  and  goats,  caused  by  Uncinaria  trigonocephala 
(Rudolphi,  1809)  Ralliet,  1900,  on  more  or  less  sandy  soil,  and  have 
further  confirmatory  facts  in  connection  with  one  outbreak  of  the 
disease  among  dogs.  Since  returning  from  my  trip  I  have  found 
at  least  one  reference  in  literature  on  uncinariasis  and  ground  itch  to 
the  effect  that  the  soil  in  districts  where  certain  cases  have  occurred 
was  more  or  less  sand}^  (see  p.  62),  but  I  have  not  yet  found  that  any 
author  lays  stress  upon  this  point. 

In  view  of  all  the  data  at  hand,  I  have  no  hesitation  in  expressing 
the  opinion  that  uncinariasis,  caused  by  Uncinaria  americana,  is  pre- 
eminently a  disease  of  sandy  localities  and  that  cases  found  in  clay  or 
rocky  areas  can  usually  be  traced  to  a  former  visit  or  residence  in  a 
sandy  place. 

Just  why  this  disease  should  follow  the  sand  rather  than  the  clay  is 
not  absolutely  clear.  Three  explanations  have  occurred  to  me  as 
working  hypotheses  which,  though  not  absolutely  satisfactory  as  final, 
will,  1  believe,  explain  part  of  the  mystery. 


49 

(1)  We  know  that  uncinariasis  is  spread  through  the  feces;  we  know 
further  that  when  the  embryos  hatch  from  the  eggs  they  leave  the 
feces  and  enter  the  surrounding  water  or  moist  earth,  while  there  is  no 
satisfactory  evidence  to  show  that  they  are  blown  around  in  the  air  in  a 
dry  state.     (See  Stiles,  1902b,  p.  199.)     Now,  assume  that  a  person  walks 
over  infected  ground;  if  that  ground  is  clay,  he  does  not  disturb  the 
embryos  which  have  crawled  beneath  the  surface,  except  in  wet  places; 
if,  on  the  other  hand,  the  ground  is  sand,  he  not  only  stirs  it  up  while 
walking,  thus  bringing  the  young  worms  nearer  the  surface  again  and 
thereby  increasing  their  chances  of  producing  an  infection,  but  he  is 
also  likely  "to  carry  away  particles  of  sand,  together  with  embryos, 
with  him  on  his  shoes  or  feet,  thus  increasing  his  chances  of  becoming 
infected.     It  is  further  clear  that  children  playing  in  sand  will  stir  up 
more  embryos  than  when  playing  on  a  clay  soil,  and  will  thus  increase 
their  chances  of  infection. 

(2)  An  additional  explanation  is  that  water  will  not  pass  through  clay 
as  it  will  through  sand;  hence  on  clay  soil  the  embryos  stand  a  greater 
chance  of  perishing  or  of  being  washed  by  rain  into  the  streams.     On 
sand,  however,  the  embryos  might  perhaps  work  their  way  through 
the  soila  with  the  water,  and  thus  infect  surface  wells.     In  advancing 
this  hypothesis,  I  am  not  unmindful  of  the  view,  supported  by  excel- 
lent observers,  that,  since  the  embryos  sink  in  water,  drinking  water 
is  not  necessarily  a  common  source  of  infection.     Granted  that  they 
do  sink  in  water,  a  water  bucket  in  a  well  also  sinks,  and  the  water 
from  surface  wells  frequently  contains  sand  particles  that  are  heavier 
and  larger  than  Uncinaria  larvae;  hence  we  can  not  altogether  ignore 
the  drinking  water  as  a  possible  source  of  infection.     If,  on  the  other 
hand,  drinking  water  were  the  only  source  of  infection,  it  is  probable 
that  in  families  where  uncinariasis  exists  the  intensity  of  the  disease 
would  show  a  greater  tendency  to  uniformity. 

Giles  has  examined  56  specimens  of  water  from  wells  and  ponds  of 
villages  affected  with  hookworm  disease  and  16  of  these  he  found  by 
chemical  and  microscopical  examination  to  be  ubad"  or  "very  bad." 
Yet  on  only  one  occasion  did  he  find  a  rhabdite  of  doubtful  origin  in 
water.  (Sandwith,  1894,  p.  9.) 

(3)  Oxygen  is  necessary  to  the  development  of  the  embryos  and 
larvae,  and  it  does  not  seem  unreasonable  to  assume  that  sand  would 

«In  an  article  which  has  just  appeared,  Looss  (1903,  p.  331)  says: 
"  Further,  during  the  six  years  of  my  residence  in  Cairo  [Egypt],  I  have  not  heard, 
up  to  the  present  time,  of  a  single  case  [of  hookworm  disease]  in  an  European  (my 
own  case,  of  course,  excepted).  This  fact  speaks  all  the  less  [so  much  the  less]  in 
favor  of  the  assumption  of  a  more  common  dissemination  [i.  e.,  infection]  of  the 
disease  through  the  drinking  water,  vegetables,  etc.,  since  [as]  the  mature  hookworm 
larvx,  as  experiments  have  shown,  pass  through  the  ordinary  sand  filter  with  surprising 
rapidity,  and  this  even  when  the  water  is  allowed,  not  to  run  off,  but  to  stand."  [Italics 
not  in  the  original  German.] 

19558— No.  10—03 4 


50 

on  that  account  present  more  favorable  conditions  for  the  growth  to 
the  "encysted  stage,  and  probably  also  a  longer  preservation  of  that 
stage. 

In  this  connection  it  may  be  noted  that  Looss  has  used  charcoal  as 
a  medium  in  which  to  cultivate  the  larvae  of  Agchylostoma  duodenale. 

INFECTION    OCCURS   CHIEFLY    IN   THE   RURAL   DISTRICTS. 

Since  the  infecting  agent  of  uncinariasis  is  spread  through  the  f eces, 
we  may  expect  to  find  infection  taking  place  (other,  things  being  equal) 
in  localities  where  the  fecal  matter  is  not  properly  disposed  of.  Fur- 
thermore, we  would  not  expect  that  paved  streets  or  grass  lawns 
would  favor  the  development  of  the  disease.  We  need  not  therefore 
expect  local  foci  of  infection  to  occur  in  cities  and  towns  which  have 
proper  sewerage  systems  and  in  which  the  streets  and  walks  are  paved 
and  the  yards  sodded;  but  we  may  expect  to  find  local  foci  of  infec- 
tion in  localities  where  box  privies  are  used  but  not  properly  cared 
for,  or  where  promiscuous  defecation  occurs  in  the  woods,  fields,  mines, 
etc.  This  condition  is  in  fact  exactly  what  is  found.  While  unci- 
nariasis is  not  entirely  absent  from  those  premises  on  which  the  feces 
are  properly  disposed  of,  in  cities  like  Washington,  Richmond,  Charles- 
ton, Macon,  Jacksonville,  and  Ocala,  such  cases  as  are  found  can  not 
be  shown  to  have  developed  there;  but  probably  in  most  every  case 
they  can  be  either  probably  or  positively  shown  to  have  been  con- 
tracted elsewhere.  In  a  number  of  cases  I  have  established  this  point 
with  a  probability,  which  for  all  practical  purposes  may  be  looked 
upon  as  a  certainty.  We  may  therefore  exclude  the  greater  portion 
of  the  inhabitants  of  sanitary  districts  of  cities  from  consideration  in 
connection  with  uncinariasis  and  may  with  confidence  lay  down  the 
general  rule  that  any  anemia  developing  in  them  as  result  of  local 
infection  (namely  infection  at  home)  is  much  more  likely  to  be  due  to 
malaria  or  other  causes  than  to  uncinariasis. 

As  we  approach  the  outskirts  of  cities  and  towns  and  enter  the  rural 
districts,  localities  in  which  box  privies  are  used  but  not  always  prop- 
erly cared  for,  we  meet  with'  conditions  which  are  more  favorable  to 
infection  with  the  hookworm  disease.  Accordingly,  in  cases  of  anemia, 
especially  in  women  and  children,  developing  in  such  localities,  unci- 
nariasis must  be  taken  into  consideration  as  one  of  the  possible  causes. 

Sandwith  (1894)  states  that  his  patients  came  from  all  parts  of  Egypt 
except  some  of  the  seaport  towns. 

As  we  go  into  the  country  and  visit  the  farms  we  not  infrequently 
find  a  condition,  in  respect  to  the  disposal  of  fecal  discharge,  which 
almost  beggars  description.  Taking  the  rural  districts  visited  during 
my  recent  trip  as  example,  it  is  not  an  exaggeration  to  say  that  with 
the  exception  of  the  planters'  premises,  not  over  half  of  the  country 
houses  or  huts  of  the  sand  regions  have  any  privy  at  all;  if  there  is 


51 

one  present,  it  is  rarely  properly  cared  for;  furthermore  it  is  the  excep- 
tion rather  than  the  rule  that  it  is  used.  As  a  result  uncinariasis  is 
widespread,  not  because  the  country  air  is  particularly  favorable  to 
its  development,  but  simply  because  so  little  attention  is  paid  to  the 
proper  disposal  of  the  fecal  discharges. 

SYMPTOMS   ARE   MORE   SEVERE    IN   SUMMER  THAN    IN   WINTER. 

It  is  almost  universally  conceded  that  the  patients  are  in  better  con- 
dition in  winter  than  in  summer.  According  to  testimony,  the  symp- 
toms begin  to  increase  in  the  spring  and  to  decrease  in  the  early  winter. 
This  periodicity  will  be  noticed,  of  course,  only  in  localities  which  are 
above  the  frost  line,  and  it  is  easily  explained  when  we  take  into  con- 
sideration the  biology  of  the  parasites.  Cold  retards  and  heat  hastens 
the  development  of  the  eggs  and  the  embryos;  a  freezing  temperature 
of  24  to  48  hours'  duration,  it  is  said,  kills  both  eggs  and  embryos. 
Accordingly,  after  frost  sets  in  in  the  fall,  the  patients  will  add  less  to 
the  infection  which  is  present  in  their  bowels  than  they  will  during  the 
summer.  Some  of  the  worms  already  in  the  intestine  will  be  passed, 
thus  decreasing  the  number  of  parasites  present;  the  patient  will 
accordingly  lose  less  blood  and  will  on  this  account  feel  somewhat 
better.  As  warm  weather  begins  in  the  spring  the  free  eggs  and 
embryos  will  develop  more  rapidly  and  the  infection  will  be  increased. 
There  will  be  more  parasites  in  the  intestine,  hence  symptoms  will  be 
augmented. 

Some  few  patients,  however,  insist  that  they  are  better  in  summer 
than  in  winter. 

It  is  probable  that  the  seasonal  periodicity  of  the  symptoms  noticed 
in  our  Southern  States  will  be  modified  in  the  Tropics,  so  that  the 
symptoms  will  increase  in  severity  in  the  rainy  season  and  decrease  in 
the  dry  period  of  the  year.  Such  a  periodicity  would  correspond  to 
the  biologic  fact  that  the  eggs  and  embryos  perish  very  quickly  upon 
becoming  dry. 

In  patients  who  are  not  subject  to  continued  infection,  as  for 
instance  those  who  have  left  the  area  of  infection,  the  seasonal 
periodicity  may  be  expected  to  disappear. 

WHITES    APPEAR  TO    BE   MORE   SEVERELY    AFFECTED   THAN    NEGROES. 

Osier  and  other  observers  have  already  noticed  that  chlorosis  is  more 
frequent  in  blondes  than  in  brunettes. 

Uncinariasis  occurs  in  both  blondes  and  brunettes,  and  in  both  the 
white  and  the  negro,  but  so  far  as  my  observations  go  the  disease  is 
more  severe,  or  at  least  more  noticeable,  in  blondes  than  in  brunettes, 
and  much  more  severe,  as  a  rule,  in  the  white  than  in  the  negro.  This 
observation  was  supported  by  all  the  evidence  I  could  gather  from 
local  physicians.  In  fact,  several  practitioners  declared  that  they  had 
never  seen  a  case  in  the  negro  to  recognize  it.  There  is,  however, 
abundant  evidence  that  such  cases  do  occur. 


52 

I  am  at  a  loss  for  a  satisfactory  explanation  of  the  comparative 
freedom  from  uncinariasis  noticed  in  the  negro.  They  live  under  the 
same  conditions  as  the  poorer  classes  of  the  white  population,  except 
that,  as  a  rule,  the  negro  farm  labor  is  more  common  in  the  rich  than 
in  the  sand  districts;  however,  negroes  also  live  in  infected  districts. 
It  is  true,  as  frequently  claimed,  that  some  of  the  negro  habitations 
are  more  clean  than  some  of  the  homes  of  the  poorer  whites.  Still, 
not  all  negro  huts  are  cleaner  than  all  white  huts.  The  personal 
habits  of  the  negro  children  are  certainly  no  more  hygienic  than  those 
of  the  white  boys  and  girls. 

One  factor  which  may  possibly  play  a  role  in  this  comparative  free- 
dom from  the  disease  on  the  part  of  the  negro  is  the  fact  that  negro 
women  very  frequently  give  their  children  "worm  tea,"  made  from 
certain  plants,  in  order  to  expel  the  "  eelworm"  (Ascaris  lumbricoides), 
or  they  give  calomel  "  to  regulate  the  liver,"  and  this  may  perhaps 
also  result  in  expelling  the  hookworms  before  the  latter  have  had  an 
opportunity  to  do  much  harm.  Still  this  explanation  is  not  altogether 
satisfactory,  especially  in  view  of  the  testimony  of  both  the  local  phy- 
sicians and  the  negroes  themselves  to  the  effect  that  eelworms  are 
much  less  common  now  than  formerly,  hence  "worm  tea"  is  not 
taken  so  frequently  as  in  former  years. 

Chabert  (1821a),  Jordan  (1832),  Imray  (1843),  Le  Conte  (1845),  Duncan 
(1850),  and  other  authors  report  "dirt-eating"  among  the  negroes.  In 
fact,  nearly  all  early  authors  who  describe  "dirt-eating"  lay  special 
stress  on  the  frequency  of  the  habit  among  the  slaves. 

In  conversation  with  a  negro  druggist,  I  was  informed  that  while 
dirt-eating  was  formerly  said  to  be  more  or  less  prevalent  among  the 
negroes,  it  was  an  acknowledged  fact  among  them  that  the  custom  had 
greatly  decreased  in  recent  years.  In  connection  with  this  statement 
we  may  note  the  interesting  claim  by  Cotting  (1836a)  that  there  was  a 
reduction  in  dropsy  and  dirt-eating  corresponding  to  the  more  general 
use  of  calomel. 

Sandwith  remarks  upon  the  apparent  comparative  freedom  of  the 
negro  from  uncinariasis  and  anemia.  Zinn  and  Jacoby  (1896)  also 
refer  to  the  frequent  presence  of  Agchylostoma  duodenale  in  negroes 
of  Africa,  in  whom  the  anemia  was  not  prominent. 

Can  it  be  that  the  poison  produced  by  the  hookworms  has  less  effect 
upon  negroes  than  on  whites  and  that  on  this  account  the  disease  is 
less  severe  in  the  dark  races? 


OCCUPATION   OF   PATIENT. 


It  is  generally  acknowledged  by  writers  on  uncinariasis  that  the 
disease  is  especially  prevalent  among  people  who  in  their  daily  work 
come  in  contact  with  earth.  In  fact,  the  malady  is  sometimes  called 
"  brickmakers'  anemia"  or  "miners'  anemia."  Sandwith  mentions 
"peasants"  as  apparently  forming  the  majority  of  his  patients. 


58 

In  my  own  work  I  was  surprised  to  find  that  hookworm  disease  was 
comparatively  light  and  comparatively  rare  among  the  miners  I  exam- 
ined. Of  brickmakers  my  statistics  are  too  small  to  permit  any  gen- 
eralization. Two  examinations  out  of  eight  showed  light  infections. 
Most  of  my  cases  were  from  the  farming  classes. 

Sandwith  emphasizes  the  fact  that  his  patients  came  from  the  poorest 
class  of  the  community,  and  that  of  200  men  190  were  accustomed  to 
work  with  their  hands  in  more  or  less  damp  earth.  Of  these  190  men, 
152  were  agricultural  laborers;  18  were  masons  or  bricklayers' 
laborers;  7  were  "scavengers  of  street  refuse  and  of  cesspools,  accus- 
tomed to  emptying  with  their  hands  the  dry  contents  of  the  latter;" 
7  were  peddlers  of  unwashed  vegetables;.  3  limestone  carters  and  scav- 
engers; 1  gardener;  1  fisherman  in  the  mud;  1  "shadouf  "  worker  at 
the  Nile  bank;  1  coffee-stall  keeper;  3  readers  of  the  Koran;  1  black- 
smith; 1  shoeblack;  4  beggars.  Sandwith  also  mentions  20  cases 
among  policemen,  who  dated  their  illness  from  periods  of  life  when 
working  as  agricultural  laborers. 

SEVERE    CASES    ARE     MORE     COMMON     IN     WOMEN     AND     CHILDREN    THAN     IN     MEN     OVER 
TWENTY-FIVE   YEARS   OF   AGE. 

The  assertion  is  frequently  made  that  uncinariasis  is  more  common 
in  men  than  in  women  and  children.  This  statement  may  be  perfectly 
correct  in  mines  and  brickyards,  but  it  does  not  hold  good  for  the 
farming  localities  I  visited,  where  the  greater  prevalence  of  severe 
cases  in  children  than  in  adults,  and  in  women  and  children  than  in 
men  over  25  years  of  age,  is  very  striking.  The  conditions  found,  in 
respect  to  this  point,  seem  to  be  due  to-  four  factors  in  particular, 
namely:  (1)  The  average  family  in  the  country  districts  numbers  from, 
say,  6  to  12.  As  a  rule,  2  or  3  of  these  can  be  called  adults,  and 
3  to  9  can  usually  be  classed  as  children  (including  minor  boys  and 
girls).  Since  there  is  a  greater  number  of  children  than  adults  sub- 
ject to  infection,  we  should  naturally  expect  to  find  a  greater  number 
of  cases  among  the  children,  and  our  expectations  are  fully  realized. 
(2)  The  fact  that  children  and  women  present  a  greater  number  of 
cases  than  do  the  adult  males  over  25  years  of  age  I  am  inclined  also 
to  explain  on  the  ground  that  the  former  are  at  home  more  than  are 
the  men;  the  area  immediately  surrounding  the  house,  for,  say,  a  radius 
of  50  meters,  is  a  more  common  place  for  defecation  than  are  the  more 
distant  fields,  hence  it  is  more  severely  infested  with  the  infecting 
agent.  Now,  while  it  is  true  that,  among  certain  classes,  both  women 
and  children  work  _in  the  fields,  it  is  also  true  that  the}7  do  this  much 
less  than  the  men.  They  are  at  home  more,  therefore  they  are  on  the 
more  intensely  infected  area  for  a  greater  length  of  time;  hence,  in 
respect  to  actual  time  they  are  more  subject  to  infection  than  are  the 
men,  and,  other  things  being  equal,  they  will  present  a  greater  num- 


54 

ber  and  a  greater  proportion  of  extreme  cases.  (3)  The  children  in 
playing  in  the  sand  around  the  house,  and  owing  to  their  more  careless 
personal  habits,  are  of  course  especially  liable  to  infection.  (4r)  The 
men  being  stronger,  are,  as  a  rule,  better  able  to  withstand  the  effects 
of  infection.  An  interesting  and  important  fact  is  that  men  of  about 
20  to  24  seem  in  many  cases  to  more  or  less  outgrow  the  effects  of  the 
malady.  They  give  a  history  of  medium  or  severe  infection  from, 
say,  10  to  18  years  of  age,  then  at  18  or  20  they  begin  to  improve, 
and  finally  appear  much  better,  although  their  features  and  physique 
still  show  the  effects  of  former  disease.  This  time  of  improvement 
corresponds  to  the  years  following  their  first  more  active  participa- 
tion in  work  which  takes  them  more  away  from  the  house,  hence  to 
years  when  they  are  subjected  less  constantly  to  infection. 

Sandwith  states  that  nearly  all  of  his  402  patients  were  in  the  prime 
of  life,  between  20  and  40  years  of  age.  His  j^oungest  case  was  a  boy 
of  6  years;  48  patients  were  between  10  and  20  years  of  age;  170 
patients  were  between  20  and  30  years  of  age;  140  were  between  30 
and  40  years  of  age;  21  were  between  40  and  50;  15  were  between  50 
and  60;  and  7  were  above  60. 

Giles  reports  a  case  of  a  girl  4  years  of  age.  My  youngest  patient 
was  3  years  old. 

Of  Sandwith's  402  cases  only  3  were  females.  This  statement  is  in 
striking  contrast  to  my  observations.  Sandwith  and  I  made  our 
studies,  however,  under  totally  different  conditions,  for  his  patients 
came  to  his  hospital,  while  I  went  to  the  homes  of  the  infected  persons. 
Possibly  this  will  explain,  in  part,  our  different  results,  for  he  states 
that  u  women  have  not  yet  learned  to  apply  for  hospital  relief  in  the 
same  proportion  as  the  men." 

SEVERAL   CASES   ARE   LIKELY   TO   OCCUR   IN   THE   SAME   FAMILY.       * 

Uncinariasis  commonly  occurs  in  groups  of  cases.  If  one  child  in  a 
family  is  accused  of  being  a  "dirt-eater,"  and  is  shown  by  physical 
and  microscopic  examination  to  represent  an  extreme  case  of  unci- 
nariasis,  an  examination  of  the  remaining  members  of  the  family  will 
usually  show  that  most  or  all  of  them  are  suffering  from  anemia  in 
different  degrees,  and  the  microscope  will  disclose  infections  with 
Uhcinaria.  This  condition  of  affairs  is  so  general  that  it  may  be 
looked  upon  as  the  rule  among  farming  classes,  while  the  occurrence 
of  isolated  cases  in  a  family,  except  possibly  among-  miners,  may  be 
looked  upon  as  the  exception.  Numerous  observations  could  be  cited 
in  support  of  this  view;  for  instance,  in  the  first  family  examined  in 
the  sand  district  near  Haile  Goldmine  only  one  member  had  the  repu- 
tation of  being  a  '"'dirt-eater,"  but  all  11  were  in  different  stages  of 
anemia.  In  a  family  of  10  members  on  a  neighboring  plantation  only 
1  was  noted  as  a  resin-chewer,  but  all  10  were  anemic.  In  orphan 


55 

asylums  it  was  noticed  that  if  two  or  more  children  of  one  family 
were  present  and  one  child  was  affected,  the  other  children  were  also 
affected.  In  fact,  in  every  instance  where  I  was  able  to  examine  the 
family  to  which  an  alleged  "  dirt-eater"  or  "  resin  chewer  "  belonged, 
all  or  nearly  all  the  members  of  the  family  showed  an  anemia  with  the 
general  history  of  uncinariasis,  and  in  every  case  examined  micro- 
scopically the  eggs  were  found. 

Two  families  may,  however,  live  very  close  together,  and  one  family 
may  show  several  severe  cases  while  the  other  may  not  show  a  single  case 
severe  enough  to  be  suspected  symptomatically.  Thus,  on  one  planta- 
tion all  the  hands  examined  showed  uncinariasis,  while  the  planter's 
family,  of  much  more  cleanly  personal  habits,  did  not  exhibit  any 
signs  of  infection.  It  is,  however,  more  common  to  find  that  where 
one  family  is  affected  other  families  of  the  same  neighborhood  will 
show  infection,  provided  of  course  that  the  infected  family  in  ques- 
tion has  not  moved  into  a  city  or  a  clay  district. 

The  occurrence  of  cases  of  uncinariasis  of  different  degrees  of 
intensity  in  family  or  neighborhood  groups  is  easily  explained  by 
the  fact  that  in  a  given  family  or  neighborhood  all  persons  are  subject 
to  the  same  general  conditions  of  infection,  but  owing  to  differences 
in  age,  daily  occupation,  personal  habits,  etc.,  some  will  be  more 
subject  to  infection  than  others. 

OBJECTIVE  AND  SUBJECTIVE  SYMPTOMS;  ANALYSIS  OF  SYMPTOMS. 

It  is  difficult  to  draw  a  distinct  line  between  the  subjective  and  the 
objective  symptoms.  If  a  patient  is  left  to  tell  his  own  story,  prac- 
tically all  that  the  observer  will  learn  is  that  the  patient  "feels  weak, 
has  a  headache,  gets  dizzy,  has  fluttering  of  the  heart,  finds  it  hard  to 
breathe,  feels  worse  in  summer  than  in  winter,  and  has  'misery'  in  the 
'stomach."  In  medium  cases  a  few  judicious  questions,  directed 
more  to  the  parents  than  to  the  patient,  will  as  a  rule  bring  to  light  a 
history  upon  which,  taken  in  connection  with  what  one  can  himself 
observe,  a  probable  diagnosis  may  be  made.  As  a  rule,  little  weight 
can  be  placed  upon  the  statements  made  by  a  patient  suffering  from 
an  severe  infection  of  uncinariasis.  He  will  answer  "yes"  or  "no" 
in  a  most  contradictory  manner,  so  that  by  putting  questions  in  differ- 
ent ways  it  is  practically  possible  to  make  him  admit  or  deny,  as 
desired,  any  particular  symptom.  It  is  chiefly  from  the  patient's 
family  that  one  must  judge  of  what  the  person  has  complained. 

ONSET   AND   INCUBATION. 

As  it  takes  the  parasites  four  to  six  weeks  to  reach  maturity  after 
entering  the  system,  the  earlier  symptoms  will  be  more  particularly 
gastro-intestinal  (see,  however,  p.  60),  and  even  if  these  are  present  in 
a  marked  degree  we  can  not  look  for  a  diagnosis  by  microscopic 


56 

examination  of  the  feces  until  the  worms  begin  to  lay  eggs.  It  is, 
however,  not  excluded  that  some  of  the  }roung  worms  might  be  passed 
in  the  stools  and  be  identified,  though  such  a  chance  is  probably 
more  theoretical  than  practical.  In  an  experimental  case  of  infection 
through  the  skin,  Looss  showed  that  eggs  did  not  appear  in  the  feces 
until  71  days  after  infection.  According  to  Sandwith  (1894,  p.  12), 
Surgeon-Major  Giles  suspected  that  many  of  his  patients  in  Assam  had 
suffered  from  fever  at  the  onset  of  their  malady,  and  he  was  confirmed 
in  this  impression  by  observing  pyrexia  in  the  monkeys  fed  on  hook- 
worm embryos. 

Looss  (1897,  pp.  914-915)  noticed  nausea  as  the  first  symptom  in 
dogs  to  which  he  fed  the  larvae  of  Agchylostoma  duodenale. 

Bentley  (1902  a)  practically  advances  the  view  that  "ground  itch"  is 
the  primary  symptom,  and  since  Looss's  view  of  infection  through 
the  skin  is  correct,  at  least  for  some  cases,  some  cutaneous  symptom 
must  in  such  instances  be  the  first  symptom  of  uncinariasis.  (See 
p.  60.) 

STAGES   OF   UNCINAKIASIS. 

Since  my  observations  of  each  patient  were  confined  to  one  or  two 
days,  they  would  not  justify  me  in  dividing  the  disease  into  stages. 
Lutz  (translated  by  Macdonald)  recognized  the  following  stages: 

I.    STAGE   OP   PURELY    LOCAL   SYMPTOMS. 

(a)  Acute  form;  (6)  chronic  form. — The  symptoms  are  similar  in  both  forms.  The 
disease  is  yet  limited  to  pains  and  disordered  digestion;  no  pallor,  no  rise  of  pulse. 

II.    STAGE   OF   SIMPLE   ANEMIA    OR   OLIGOCYTHEMIA    (CHLOROTIC   STAGE). 

(a)  Acute  form. — 1.  Slight  degree:  Conjunctival  vessels  still  visible;  nails  and  lips 
pale  red;  pulse  increased  in  frequency;  no  blowing  murmurs  over  cardiac  area. 

2.  Higher  degree:  Conjunctive  devoid  of  vessels;  nails  whitish;  lips  pale;  pulse 
frequently  very  much  increased;  no  blowing  murmurs. 

(b)  Chronic  form. — Anemia  has  not  reached  the  highest  degree.     In  many  cases 
distinct  cardiac  hypertrophy  and  dilatation;  in  other  cases  disordered  valve  closure; 
seldom  both  combined.     Moderate  increase  of  frequency  of  pulse. 

III.    DROPSICAL   STAGE. 

(a)  Acute  form. — A  high  degree  of  anemia;  pulse  small,  much  increased  in  fre- 
quency; no  blowing  murmurs;  edema  of  a  hydremic  character. 

(b)  Chronic  form. — Symptoms  of  ca-rdiac  defects,  with  disturbed  compensation,  or 
of  fatty  degeneration;    distinct  symptoms  of  cyanosis;    dropsy  of   engorgement; 
anemia  of  varying  intensity;  disordered  nutrition. 

DURATION   OF   UNCINAKIASIS. 

In  speaking  of  the  duration  of  uncinariasis,  we  should  clearly  dis- 
tinguish between  the  duration  of  cases  which  remain  in  the  infected 
areas,  and  the  duration  of  cases  which  after  once  becoming  infected 
move  to  uninf ested  districts  where  conditions  are  such  that  reinfection 
is  excluded. 


57 

Tn  the  former  instance  we  have  to  deal  with  cumulative  infection, 
taking  place  week  after  week  and  year  after  year,  hence  successive 
generations  of  parasites  come  into  consideration. 

In  the  latter  instance  we  have  to  deal  with  the  individual  life  of  the 
parasites  which  are  present  in  the  patient  at  the  time  he  leaves  the 
infested  area. 

A  failure  on  the  part  of  most  observers  to  distinguish  between  these 
two  classes  of  cases  renders  the  published  data  less  valuable  than  they 
otherwise  would  be  in  determining  the  duration  of  uncinariasis. 

In  my  own  observations,  I  have  found  people  remaining  in  the 
infested  areas  who  gave  a  history  of  the  disease  extending  back  for 
ten,  twelve,  and  even  fifteen  years.  I  have  further  three  observations 
which  I  consider  free  from  criticism  in  connection  with  patients  who 
presented  the  disease  six  years  (2  cases)  and  even  six  years  and  seven 
months  (1  case)  after  being  removed  from  the  source  of  infection.  I 
also  have  one  observation,  which  is  not  free  from  criticism,  upon  a 
patient  who  showed  the  disease  ten  years  after  entering  a  hospital. 

Sandwith  (1894,  p.  15)  in  discussing  the  duration  of  illness  says— 

"Nearly  every  patient  said  he  had  been  ill  two  or  three  years  before  admission. 
I  find  among  my  notes  29  cases,  uncomplicated  by  other  diseases,  where  the  patients 
said  they  had  suffered  more  than  three  years.  Of  these,  13  had  been  ill  for  four 
years,  6  for  five  years,  3  for  six  years,  2  for  eight  years,  2  for  nine  years,  2  for  eleven 
years,  and  one  vowed  it  was  fifteen  years  since  the  commencement  of  his  symptoms. 

"It  may  be  safely  said  that  during  these  long  intervals  of  time  very  few  patients 
had  any  rational  treatment." 

It  is  probable  that  Sandwith's  cases  were  subject  to  cumulative 
infections. 

LENGTH    OF   LIFE   OF   THE   INDIVIDUAL    PARASITES. 

It  is  already  established  that  for  ever}T  hookworm  which  is  present 
in  the  intestine  a  separate  embryo  must  enter  the  body.  In  other 
words,  the  eggs  which  the  female  worm  deposits  in  the  intestine  will 
riot  develop  there  to  mature  parasites,  but  must  first  be  discharged  in 
the  feces  and  undergo  certain  changes. 

It  is  further  clear  that  direct  autoinfection,  such  as  takes  place  in 
the  case  of  pinworms  (Oocyuris  vermicularis),  is  excluded.  For 
instance,  suppose  a  child  is  at  stool  and  soils  his  fingers  with  the 
feces,  which  contain  hookworm  eggs,  then  puts  his  fingers  into  his 
mouth  and  swallows  the  eggs;  these  ova  will  not  develop  in  the 
bowels  into  adult  worms. 

Whether  an  Uncinaria  egg,  which  happened  to  get  under  the  finger 
nails,  could  reach  the  larval  infecting  stage  in  that  place  is  perhaps  an 
open  question.  So  far  as  1  am  aware,  the  point  has  nover  been 
studied,  but  what  is  already  known  about  this  group  of  parasites  does 
not  lead  me  to  believe  that  such  a  condition  would  be  especially 
common,  although  it  does  not  seem  absolutely  impossible. 


58 

With  the  foregoing  premises  in  mind,  it  is  important  to  determine 
how  long  the  parasite  in  the  intestine  can  live.  Regarding  the  Ameri- 
can hookworm,  Uncinaria  americana,  I  can  present  the  following 
data:  Of  children  at  the  Charleston  Orphan  Asylum  in  whom  I 
demonstrated  the  presence  of  Uncinaria  americana  microscopically, 
it  may  be  noted  that  8  children  had  been  in  the  orphan  asylum  two 
37ears  or  less;  4  children  had  been  in  the  asylum  between  two  and  three 
years;  2  children  had  been  in  the  asylum  six  years;  1  child  had  been 
in  the  asylum  six  years  and  seven  months. 

I  have  selected  the  Charleston  Orphan  Asylum  as  best  fulfilling  the 
conditions  desired  to  illustrate  the  point  at  issue.  The  refined  disci- 
pline, the  scrupulous  cleanliness,  and  the  general  hygienic  conditions 
noticed  are  such  that  local  infection  is  practically  excluded.  It  must 
be  admitted  that  some  persons  coming  in  from  the  country  might 
possibly  bring  on  their  shoes  a  few  embryos,  but  such  a  theoretical 
possibility  is  altogether  too  remote  to  explain  the  15  cases  found. 

For  all  practical  purposes  we  are  justified  in  assuming  that  the 
hookworms  which  these  15  children  had  in  them  when  I  saw  them 
wTere  the  same  individual  worms  which  were  in  the  children  when  the 
latter  entered  the  asylum,  and  from  the  data  obtained  it  is  clear  that 
hookworms  of  the  species  Uncinaria  americana  are  capable  of  living 
six  years  and  even  six  years  and  seven  months. 

A  sixteenth  child  (case  of  L.  B.)  examined  showed  a  clear  clinical 
history  of  uncinariasis  of  long  standing.  Her  condition  at  the  time 
of  entering  the  institution,  as  described  to  me  by  Dr.  Huger,  and  her 
present  complexion,  eyes,  stunted  growth,  and  inferior  mental  develop- 
ment leave  no  practical  doubt  in  my  mind  regarding  the  diagnosis. 
No  normal  eggs  were  found  in  her  stools,  despite  the  fact  that  1  made 
25  slides.  One  slide  showed  a  single  abnormal  egg  which  had  evi- 
dently been  dried  and  had  clung  to  the  slide  after  an  examination  in 
some  other  town.  1  do  not  know  this  girl's  complete  therapeutic  his- 
tory during  the  past  twelve  years,  but  from  the  absence  of  eggs  in  her 
stools  it  is  necessaiy  to  conclude  either  that  the  worms  had  been 
expelled  by  the  drugs  taken  or  else  Uncinaria  americana  is  not  able 
to  live  twelve  years. 

Ashford»(see  Stiles,  1902b,  p.  210)  mentions  a  case  where  a  boy  "had 
been  the  host  of  the  worm  for  probably  ten  or  fifteen  years,"  but  he 
does  not  state  that  during  this  time  the  patient  was  not  exposed  to 
further  infection. 

The  clinical  importance  of  the  length  of  the  life  of  the  parasite  is 
self-evident.  Suppose  a  physician  in  the  North  has  an  anemic  patient, 
or  a  physician  in  the  South  has  an  anemic  patient  who  lives  in  the  city 
or  in  a  clay  district;  it  is  not  sufficient  to  inquire  whether  he  or  she 
has  recently  been  exposed  to  malaria,  but  inquiry  should  extend  for 
eight  or  more  years  back  in  order  to  develop  the  fact  whether  she  has 


59 

during  this  time  visited  any  tropical  or  subtropical  sand  area.  If  such 
a  fact  does  develop,  uncinariasis  is  among  the  probabilities  and  a 
microscopic  examination  of  the  feces  should  be  made. 

GENERAL    EXTERNAL    APPEARANCE. 

GENERAL   LACK    OF   DEVELOPMENT — STUNTED   GROWTH. 

In  severe  cases  of  long  standing  the  patient  is  undeveloped  both 
plrysically  and  mentally.  A  boy  or  girl  12  to  14  years  old  may  be  as 
small  as  the  average  child  of  6  or  8;  a  young  man  or  woman  of  18  to 
22  years  old  may  present  the  general  development  of  a  child  12  to  16 
years  of  age,  but  the  face  may  appear  either  like  that  of  a  child  or 
like  that  of  a  very  old  person,  especially  like  that  of  an  elderly  dwarf. 
Similar  conditions  have  been  described  as  a  symptom  of  dirt-eating. 

SKIN. 

The  skin  has  an  anemic,  waxy  white  to  a  yellow  or  tan,  shriveled, 
parchment-like  or  tallow  appearance.  In  general  it  is  that  color 
known  in  the  South  as  a  "Florida  complexion."  In  some  cases  of 
malaria,  if  one  trusts  too  much  to  the  appearance  of  the  skin,  he  is 
likely  to  be  misled  into  an  erroneous  diagnosis  of  uncinariasis,  but  the 
general  clinical  history  is  usually  sufficient  to  distinguish  between 
the  two  diseases,  while  the  microscopic  examination  gives  a  positive 
diagnosis.  (See  also,  Temperature,  p.  72.) 

Wounds  heal  slowly. — Among  the  first  severe  cases  of  uncinariasis 
found,  I  noticed  that  several  of  the  patients  wore  bandages.  Suspect- 
ing the  possibility  of  ground  itch  and  recalling  Looss's  and  Bentley's 
theories  (see  below),  I  immediately  inquired  into  the  history  of  the 
sores.  According  to  the  testimony  of  the  patients  the  ulcers  present 
had  started  as  small  wounds  produced  mechanically;  the  wounds  had 
failed  to  heal  promptly,  had  grown  worse,  and  were  now  about  a 
year  old.  This  same  story  was  related  to  me  by  quite  a  number  of 
patients,  and  many  other  persons  suffering  from  uncinariasis  assured 
me  that  in  their  cases  cuts  and  bruises  healed  very  slowly,  testimony 
which  was  repeatedly  corroborated  by  local  physicians. 

Cutaneous  lesions  caused  by  uncinariasis. — The  statements- just  made 
lead  to  a  consideration  of  certain  views  recently  advanced  by  Looss 
and  Bentley. 

Looss's  theory  of  cutaneous  infection.—  Looss  (1901)  has  shown  that 
if  a  drop  of  water  containing  embryos  of  Agchylostoma  duodenale  is 
placed  upon  the  skin  an  itching  sensation  is  produced;  the  worms 
enter  the  hair  follicles,  and  from  there  they  seem  to  bore  into  the 
surrounding  tissues.  Looss  further  advanced  the  rather  startling 
opinion  that  the  larvae  then  reached  the  intestine,  and  he  recounted 
observations  which  gave  a  certain  amount  of  plausibility  to  this  view. 


60 

More  recently  (see  Sandwith,  1902),  Looss  has  performed  experiments 
which,  so  far  as  can  be  judged  at  present,  demonstrate  the  correctness 
of  his  theory.  According  to  Sandwith  (1902),  Looss0  smeared  on  the 
back  of  a  puppy  a  mixture  of»  charcoal  and  feces  in  which  hookworm 
larvae  had  been  bred.  Between  nine  and  ten  days  afterward  the 
puppy  died  and  was  found  to  have  anemia  of  most  of  his  organs,  and 
a  plentiful  supply  of  young  hookworms  was  found  in  his  jejunum.  A 
second  puppy  was  treated  in  a  similar  way  and  also  died  on  the  night 
between  the  ninth  and  tenth  days.  Upon  post-mortem  he  also  showed 
exactly  the  same  results.  A  man  who  offered  himself  for  experiment 
was  also  similarly  treated  on  his  forearm,  and  in  his  case  the  first 
hookworm  eggs  were  discovered  in  his  feces  on  the  seventy-first  day. 
In  all  three  experiments  the  feces  were  regularly  examined  for  some 
weeks  prior  to  the  experiments,  so  that,  so  far  as  we  can  now  judge, 
the  results  must  be  accepted,  despite  their  very  startling  nature. 
Furthermore,  Looss  is  known  as  too  careful  an  investigator  to  permit 
any  foreseen  error  to  creep  into  his  conclusion. 

Somewhat  similar  results,  namely  the  entrance  of  embryos  into  the 
skin,  have  been  obtained  by  van  Durme  (1902,  pp.  4:71-474)  in  experi- 
ments with  Strongyloides  stercoralis  on  guinea  pigs,  and  it  is  needless 
to  insist  on  the  great  importance  of  Looss's  demonstration. 

Bentley*  s  theory  of  ground  itch. — In  line  with  Looss's  views,  Bentley 
(1902a)  has  made  certain  exceedingly  important  observations  and 
experiments,  the  logical  conclusion  of  which,  taken  in  connection 
with  Looss's  work,  seems  to  be  that  at  least  certain  forms  of  ground 
itch  constitute  the  initial  symptom  of  uncinariasis.  Bentley  defines 
ground  itch  as  follows: 

Ground  itch — Synonyms:  Panighao,  water  itch,  water  pox,  water  sores,  sore  feet  of 
coolies — is  an  affection  of  the  skin,  confined  entirely  to  the  lower  extremities,  and 
probably  always  associated  with  the  presence  of  the  larvae  of  Ankylostoma  duodenale 
in  the  soil  of  the  affected  areas;  endemic  in  Assam  and  the  West  Indies  and  possibly 
present  in  other  parts  of  the  Tropics;  characterized  by  its  periodical  epidemic 
appearance  in  the  infected  areas,  coincident  with  the  onset  of  the  rainy  season;  with 
typical  lesions  consisting  in  a  primary  erythema,  followed  by  vesicular  eruption, 
which  frequently  becomes  pustular  and  in  severe  cases  may  result  in  obstinate 
ulceration,  or  even  gangrene. 

Dr.  Seheult  (1900),  of  Trinidad,  has  suggested  that  the  disease  is 
probably  due  to  some  chemical  irritant  present  in  the  soil,  either 
natural  or  due  to  manure  used  in  cultivation.  Dr.  Dalgetty  (1901),  of 
South  Sylhet,  struck  by  the  resemblance  which  the  lesions  bear  to 
scabies,  and  finding  a  mite  present  which  he  named  Rhizoglyphus 
parasiticus,  assumed  this  acarine  to  be  the  cause.  These  authors  and 
Bentley  (1902a)  seem  to  agree  that  ground  itch  is  a  filth  disease  which 

« During  the  proof  reading  of  the  present  report,  Looss's  (1903)  article,  detailing 
his  brilliant  experiments,  has  appeared.  He  demonstrates,  beyond  any  question  of 
a  doubt,  the  correctness  of  his  contention  that  infection  with  hookworms  may  take 
place  through  the  skin. 


61 

is  increased  by  the  lack  of  care  given  to  the  proper  disposal  of  alvine 
discharges. 

Bentley  (1902a)  found  in  a  water  sore  a  young  worm  which  he  con- 
sidered to  be  identical  with  Agchylostoma  duodenale.  He  then  per- 
formed the  following  experiments— 

(/.  Some  ordinary  soil  was  sterilized  by.  heat,  and  after  being 
moistened  with  sterilized  water,  was  infected  with  a  small  quantity  of 
fecal  matter  containing  numerous  ova  of  Agchylostoma  duodenale. 

1).  A  similar  preparation  of  soil  was  infected  with  a  small  quantity 
of  f eces,  which  on  examination  was  found  to  be  free  from  -hookworm 
infection. 

These  two  preparations  were  incubated  at  the  ordinary  temperature 
of  the  air  for  about  a  week,  when  sample  "«"  was  found  to  be  swarm- 
ing with  larval  hookworms  and  various  forms  of  bacteria  and  fungi, 
and  sample  u  1) "  was  similar  in  appearance  except  that  no  hookworm 
[larvaB  were  found. 

1  Each  sample  was  then  divided  into  two  parts,  a'  and  a"  and  b'  and 
1)" .  Samples  a'  and  ft  were  kept  moist,  while  a"  and  b"  were  gently 
dried  by  exposure  to  the  air  for  eight  hours.  Previous  experiments 
had  shown  that  six  hours  gentle  drying  at  ordinary  temperatures  was 
sufficient  to  kill  the  hookworm  larvae.  After  remoistening  a"  and  b" 
with  sterilized  water,  the  four  samples  were  applied  to  the  wrists  of 
the  subjects  of  experiment  for  eight  to  nine  hours,  and  then  they  were 
removed.  Fifteen  hours  after  the  first  application,  considerable  ery- 
thema with  a  minute  papular  eruption  appeared  over  the  spot  to  which 
a'  had  been  applied;  within  twenty-four  hours  a  distinctly  vesicular 
eruption  had  developed,  followed  by  pustules  exactly  resembling  those 
found  in  the  lesions  of  ground  itch.  In  the  other  cases  a  faint  redden- 
ing of  the  skin  was  produced,  which  shortly  afterwards  disappeared. 
A  reexamination  of  sample  a1  now  showed  that  no  live  larvae  were 
present,  although  one  or  two  dead  worms  were  found.  Sample  a" 
still  contained  the  dead  larvae.  Apparently,  therefore,  the  live  larvae 
I  a'  had  entered  the  skin  and  their  entry  had  been  followed  by  lesions 
similar  to  those  found  in  water  sore. 

According  to  Bentley,  also,  it  is  probable  that  the  acuteness  of  the 
inflammation  attending  an  attack  of  the  ground  itch  is  largely  governed 
by  the  nature  of  the  organisms  which  accompany  or  follow  the  larval 
hookworms  in  their  passage  through  the  skin. 

Regarding  the  treatment  of  ground  itch,  Bentley  says  that  in  the 
papular  and  early  vesicular  stage  of  the  disease  the  application  of  a 
strong  solution  of  salicylic  acid  in  collodion  or  methylated  spirit  will 
cause  the  eruption  to  dry  up,  and  so  cut  short  the  attack  of  the  disease 
to  one  or  two  days.  If,  however,  pus  has  formed,  the  only  treatment 
\  of  any  service  is  the  opening  up  and  disinfection  of  the  pustules  with 
pure  carbolic  acid,  silver  nitrate,  or  nitric  acid,  and  the  after  treatment 
of  the  sore  as  an  ordinary  ulcer.  In  cases  attended  with  great  swell- 


62 

ing,  inflammation,  and  tendency  toward  the  formation  of  sloughs,  free 
skin  incisions  and  the  use  of  hot  antiseptic  footbaths  are  indicated. 

Dalgetty  (1901,  p.  77)  advises  the  application  of  a  strong  solution  of 
lime  and  sulphur;  strong  phenyl  solution  is  also  beneficial,  and  a  coat- 
ing of  coal-tar  acts  for  a  time  as  a  preventative  against  infection;  but 
when  once  the  vesicles  have  formed  pustules  are  sure  to  follow,  and 
then  the  only  remedy  is  to  open  them,  evacuate  the  pus,- and  thoroughly 
cleanse  them. 

An  anonymous  writer  (?  Dr.  Elliot,  of  Assam)  in  the  Journal  of 
Tropical  Medicine  (1900),  gives  the  following  directions: 

"  The  indications  are  to  get  the  case  as  soon  as  possible;  to  carefully  cleanse  the  foot 
by  soaking  it  in  warm  antiseptic  solution;  then  open  the  vesicles  with  sharp  pointed 
scissors,  snip  the  loose  skin  away,  and  finally  wash  the  parts  with  carbolic  acid  solu- 
tion (1  in  40),  and  treat  the  resulting  ulcer  with  carbolic  acid,  phenyle  oil,  extract 
of  paroli  leaf,  zinc  ointment,  etc.,  according  to  circumstances.  The  soaking,  wash- 
ing, and  dressing  operations  are  repeated  once  or  twice  daily,  and  healing  takes  place 
in  eight  or  nine  days  in  favorable  cases." 

It  will  be  noticed  that  Bentley  does  not  definitely  state  that  he  adopts 
Looss's  view  of  intestinal  infection  through  the  skin;  nor  does  he  defi- 
nitely state  that  the  hookworm  larvae  act  as  anything  more  than  carriers 
of  bacteria.  The  conclusion  would  therefore  seem  to  be  that  the  ground 
itch  with  which  he  was  dealing  is  a  bacterial  infection  due  very  prob- 
ably to  fecal  bacteria. a  If  this  interpretation  is  correct,  its  dependency 
upon  uncinariasis  does  not  seem  to  be  proved,  although  its  occurence 
with  the  disease  would  seem  to  be  established. 

Additional  facts  (besides  Bentley's  experiments)  which  support 
the  view  that  the  ground  itch,  with  which  he  was  dealing,  is  more  or 
less  connected  with  hookworm  infection  are  the  following: 

Ground  itch  occurs  in  the  warm  rainy  season,  especially  in  June, 
July,  August,  and  September,  and  does  not  occur  in  cold  weather, 
even  when  it  rains;  thus  the  seasonal  distribution  in  general  agrees 
with  the  infection  period  of  uncinariasis.  Grass-covered  soil  and 
smooth  beaten  roads  do  not  cause  it,  neither  does  working  in  loose  dry 
soil;  and  these  conditions  are  unfavorable  to  the  development  of 
uncinariasis.  The  number  of  cases  increases  after  a  heavy  rain  and 
rapidly  decreases  during  a  hot  spell,  a  fact  which  agrees  with  the 
biology  of  hookworms.  "  The  soil  itself  is  sandy,  with  clay  here  and 
there;  a  belt  of  pure  sand,  40  to  60  feet  thick,  lies  at  a  depth  of  6  to 
18  feet  from  the  surface;"  and  uncinariasis  is  preeminently  a  sand 
disease. 

Still  the  question  is  not  quite  so  simple  as  would  at  first  appear,  and 
in  connection  with  the  subject  the  following  points  come  up  for  con- 
sideration : 

^Looss  has,  however,  proved  that  certain  cutaneous  symptoms  follow  the  entrance 
of  hookworm  larvae  into  the  skin. 


63 

1.  According  to  Bentley,  ground  itch  is  confined  entirely  to  the 
lower  extremities,  and  other  authors  state  that  it  rarely  extends  above 
the  ankles.     According  to  the  physicians  in  Georgia  and  Florida,  it  is 
found  on  other  parts  of  the  body  also.     I  saw  one  case,  said  to  be 
typical,  where   the   disease  was  confined  to  one  arm.     Under  these 
conditions  is  the  panighao,  discussed  by  Bentley,  identical  with  the 
so-called  "  ground  itch"  which  is  so  common  in  the  southern  portion 
of  the  United  States,  or  is  only  a  part  of  the  American  "  ground  itch" 
produced  by  hookworm  larvse? 

2.  If  ground  itch  is  the  initial  stage  of  cutaneous  infection  with 
uncinariasis  (as  Looss's  and  Bentley 's  views  would  seem  to  indicate), 
why  should  it  be   confined   entirely  to   the   lower  extremities?     If 
infection   by  uncinariasis  frequently  takes  place  through  the  skin, 
would  not  the  hands  and  arms  also,  especially  of  children,  and  more 
particularly  the  soles  of  the  feet  and  the  palms  of  the  hands,  the 
spaces  between  the  toes  and  fingers,  and  under  the  toe  nails  and  finger 
nails,  be  the  most  common  initial  points  of  ground  itch  in  case  this 
latter  is  an  initial  symptom  of  uncinariasis  ? 

3.  On  the  same  premises  would  we  not  commonly  find  lesions  corre- 
sponding to  ground  itch  on  the  abdomen  of  cattle,  sheep,  goats,  dogs, 
cats,  foxes,  seals,  and  other  animals  suffering  from  uncinariasis?     I 
will  not  deny  that  such  lesions  occur,  but  I  have  seen  many  cases  of  hook- 
worm disease  in  certain  of  these  animals  and  I  have  no  recollection  of 
having  observed  anything  which  corresponded  to  ground  itch.     If  it 
were  as  prominent,  in  the  animals  named,  as  the  typical  "ground  itch" 
of  man  which  I  saw  in  Georgia,  I  doubt  whether  I  should  have  over- 
looked it.     Possibly  I  did  not  have  recent  infections  before  me. 

4.  According  to  the  testimony  of  Georgia  and  Florida  physicians 
"ground  itch"  is  exceedingly  common;  it  occurs  at  some  period  in  the 
life  of  practically  every  person,  unless  he  lives  exclusively  in  the  city; 
it  occurs  in  the  healthy  as  well  as  in  the  sickly,  and  in  persons  who 
neither  at  the  time  of  infection  nor  later  show  the  slightest  evidence 
of  anemia.     These  statements,  which  I  have  repeatedly  heard  from 
Southern  physicians,  can  not  be  said  to  indicate  that  Bentley's  views 
are  applicable  to  all  cases  of  "ground  itch"  as  we  find  this  disease  in 
this  country. 

5.  "Ground  itch"  is  said  to  be  common  in  clay  districts  as  well  as  in 
sand  districts.     Under  these  circumstances,  why  is  uncinariasis  so  pre- 
eminently a  disease  of  the  sand  areas  ? 

6.  Bentley  states  that  "ground itch"  is  probably  always  associated 
with  the  presence  of  the  larvae  of  Agchylostoma  duodenale  in  the  soil 
of  the  affected  areas.     Doubts  may,  however,  arise  as  to  whether  a 
sufficiently  wide  geographic  range  has  been  examined  in  connection 
with  this  point. 

In  view  of  the  above  considerations,  it  will  be  well  to  remain  open 


64 

to  conviction  awaiting  a  more  thorough  demonstration  of  the  broad 
application  of  Bentley's  interesting  and  valuable  views.  But  until 
better  proof  is  advanced  than  has  thus  far  been  brought  to  m}^  atten- 
tion, I  find  it  impossible  to  unreservedly  adopt  the  opinion  that  Amer- 
ican ground  itch  is  necessarily  connected  with  uncinariasis. 

While  not  opposing  the  theory  of  infection  through  the  skin,  but 
admitting,  on  the  contrary,  that  Looss  has  proved  his  point,  I 
may  state  that  the  conditions  which  I  saw  in  the  southern  portions 
of  the  United  States  do  not  indicate  that  any  indirect  method  of  intes- 
tinal infection  is  necessary  in  order  to  explain  the  severe  cases  of 
uncinariasis  observed.  The  average  boy  or  girl  suffering  from  this 
disease  is  not  conspicuous  because  of  personal  cleanliness.  Bath  tubs 
are  not  found  in  their  homes,  and  from  physical  examinations  I  made 
I  can  testify  that  not  only  their  hands  and  finger  nails,  but  their  entire 
bodies  also,  are  far  from  a  condition  unfavorable  to  parasitism.  Suck- 
ing the  fingers,  picking  the  teeth,  biting  the  finger  nails,  or  even  eat- 
ing a  piece  of  bread  with  soiled  hands  will  usually  suffice  to  convey 
some  dirt  between  the  lips.  The  sand  on  which  the  children  play 
must  be  heavily  infested  with  hookworm  larvae,  and  it  certainly  can 
not  be  an  exceptional  occurrence  that  the  children  unconsciously  carry 
microscopic  worms  to  their  mouth.  Further,  the  chances  for  infec- 
tion of  surface  wells,  from  which  the  drinking  water  is  taken,  are  very 
great  in  any  sandy  soil.  If,  however,  cutaneous  infection  were  the 
rule,  I  should  expect  to  find  all  barefooted  children  in  the  infested 
area  suffering  not  only  from  ground  itch  the  entire  summer,  but  also 
from  severe  infections  of  hookworm  disease. 

Hair. — The  hair  on  the  head  appears  to  be  about  normal,  but  in  cases 
contracted  before  puberty,  the  beard  and  the  hair  on  the  body  (pubis, 
armpits,  arms,  legs)  are  usually  undeveloped.  I  have  seen  patients 
20  years  of  age  upon  whose  body  hairs  were  almost  absolutely  lacking. 

Breasts. — The  breasts  of  females,  who  have  contracted  hookworm 
disease  before  puberty,  remain  more  or  less  undeveloped.  In  a  girl 
of  20  years  of  age,  for  instance,  the  breasts  may  not  be  developed 
beyond  those  of  a  girl  of  8  or  9  years  old. 

Nails.—  The  color  of  the  tissue  directly  under  the  nails  varies  with 
the  anemia. 

HEAD. 

Face. — The  face  has  an  anxious,  stupid  expression,  and  in  severe 
cases  is  more  or  less  "bloated"  (edematous). 

In  fact,  a  prominent  symptom  of  uncinariasis  in  practically  all 
animals  in  which  it  occurs  is  the  development,  in  severe  cases,  of  a 
more  or  less  extreme  edema.  To  use  the  rural  vernacular,  "the  face 
bloats,"  and  "the  feet  and  ankles  swell."  The  symptom  in  question 
is  more  or  less  irregular  in  man  as  it  is  in  other  animals,  notably  in 
sheep,  appearing  and  disappearing  at  intervals.  Upon  several  occa- 


65 

sions  I  was  informed  that  this  symptom  interfered  seriously  with  the 
school  attendance,  for  if  the  children  sat  still  a  long  time  in  school 
"they  began  to  swell."  Quite  generally,  as  was  to  be  expected, 
testimony  was  to  the  effect  that  the  edema  was  less  frequent  in  the 
winter  than  in  the  summer. 

Eyelids;  conjunctivas. — An  examination  of  the  eyelids  exhibits  the 
visibility  of  the  blood  vessels  in  light  cases,  but  an  absolute  marble 
whiteness  in  very  severe  cases,  with  all  possible  intermediate  stages 
corresponding  to  the  general  degree  of  anemia. 

Eyes. — While  looking  at  the  eyelids  for  anemia,  the  observer  fre- 
quently notices  that  the  pupils  are  dilated  or  that  they  dilate  readily 
and  that  the  eyes  are  dull,  dry,  and  usually  of  a  chalky  white.  If  the 
patient  is  directed  to  stare  intently  into  the  observer's  eyes,  there  will 
be  noticed  a  symptom  which  it  is  difficult  to  describe,  but  which  I  have 
found  more  constant  than  almost  any  other  noticed,  namely:  After  a 
moment,  the  length  of  time  apparently  varying  slightly  according  to  the 
degree  of  the  disease,  the  pupils  dilate  and  the  patient's  eyes  assume  a 
dull,  blank,  almost  stupid,  fish-like  or  cadaveric  stare,  very  similar  to 
that  noticed  in  cases  of  extreme  alcoholic  intoxication.  I  am  not  familiar 
enough  with  the  stare  of  anemic  patients  in  general  to  state  how 
common  this  peculiar  look  is  among  them,  nor  have  1  found  any  of  my 
medical  friends  who  could  give  me  much  information  on  this  subject; 
but  I  can  state  that  among  the  several  scores  of  anemic  people  whom  I 
examined  on  this  trip,  in  the  severe  cases  with  two  exceptions,  I  found 
the  eggs  of  Uncinaria  americana  in  every  one  (whose  feces  were  ex- 
amined) in  whom  I  observed  that  indescribable  stare;  the  two  excep- 
tions in  question  were  city  boys,  both  of  them  sons  of  a  confirmed 
inebriate;  further  I  failed  to  find  the  eggs  present  in  certain  extremely 
anemic  patients  in  whom  the  stare  was  not  noticed.  It  certainly  was 
absolutely  absent  from  a  number  of  typical  cases  of  malaria.  Toward 
the  end  of  the  trip,  I  found  myself  unconsciously  relying  more  upon 
the  presence  or  absence  of  the  blank  stare  than  upon  any  other  single 
symptom,  except  of  course  the  presence  of  the  eggs  in  the  stools. 

I  will  not  go  to  the  extent  of  stating  that  this  stare  is  diagnostic  for 
uncinariasis  (and  I  will  even  warn  that  in  dark  eyes  it  is  less  evident 
than  in  eyes  of  light  color),  for  1  do  not  feel  that  I  have  had  experi- 
ence enough  with  the  peculiarities  of  eyes  in  various  diseases  to  speak 
authoritatively  upon  the  subject.  I  simply  mention  this  pecul- 
iarity in  connection  with  the  discussion  of  the  eye  as  a  symptom 
which,  as  my  investigations  progressed,  made  more  and  more  of  an 
impression  upon  me.  Upon  calling  the  attention  of  several  local  physi- 
cians to  this  peculiar  stare,  they  informed  me  that  it  was  a  totally  new 
symptom  to  them,  but  that  after  examining  several  cases  they  found 
it  a  very  prominent  symptom.  As  a  general  rule  the  eyes  in  advanced 
stages  are  dry.  In  this  connection  it  may  be  noticed  that  several 

19558— No.  10—03 5 


66 

authors  have  mentioned  the  glassy  appearance  of  the  eyes  of  dirt- 
eaters. 

Since  my  return,  several  of  my  clinical  friends  with  whom  I  have 
discussed  this  symptom  have  expressed  some  skepticism  in  regard 
to  the  matter.  Although  thoroughly  convinced  of  its  existence,  for 
I  saw  it  too  frequently  to  be  deceived,  I  have  written  to  several 
Southern  clinicians  requesting  them  to  give  me  the  benefit  of  their 
independent  observations  on  this  point.  Up  to  the  time  of  reading 
"  galley  proof"  of  this  report  the  following  replies  have  been  received: 

[Extract  from  a  letter  from  Dr.  Hilsman,  January  2,  1903.] 

' '  Replying  to  your  letter,  24th  ultimo,  I  have  to  say  that  I  have  examined  the 
patients  that  we  saw  in  the  country,  and  on  making  them  gaze  intently  at  me  as  you 
directed,  I  observed  the  vacant  stare  that  you  described,  but  did  not  observe  the 
dilation  of  the  pupils.  The  stare  is  very  much  like  that  of  an  epileptic  as  he  begins 
to  recover  from  a  fit. 

"These  cases  have  improved  under  treatment  suggested  by  you.  The  little  girl 
passed  a  large  number  of  the  worms." 

[Extract  from  a  letter  from  Dr.  M.  A.  Clark,  January  30,1903.] 

"I  have  delayed,  hoping  to  find  the  eye  symptom  you  mention,  but  I  have  not  yet 
found  it.  My  cases  are  improving  slowly." 

Dr.  James  Edward  Stubbert,  of  New  York,  who  spent  some  years 
in  Central  America  and  has  seen  many  cases  of  hookworm  disease,  has 
stated  to  me  that  he  has  frequently  observed  the  peculiar  stare  in  the 
eyes  of  dirt-eaters. 

In  this  connection  it  is  also  not  uninteresting  to  note  that  some 
"worm  doctors"  claim  to  lay  special  stress  upon  the  eye  in  making 
their  diagnoses;  also  that  dilation  of  the  pupil,  due  to  irritation  by 
intestinal  worms  as  well  as  to  anemic  conditions,  is  recognized  by 
certain  prominent  writers  on  the  eye;  further,  that  dilation  of  the 
pupil  is  also  a  symptom  upon  which  many  children's  nurses  depend 
in  suspecting  the  presence  of  worms. 

Sandwith  (1894,  p.  12)  states  that  the  eyes  of  his  patients  showed  a 
pearly  white  conjunctiva,  singularly  in  contrast  with  the  yellow  color 
of  the  face.  Dr.  Scott  examined  several  men  for  him  with  the 
ophthalmoscope,  and  found  in  half  of  them  a  normal  f undus,  and  in  the 
other  half  a  very  pallid  fundus.  The  refraction  tests  showed  astig- 
matism in  many  cases. 

Nostrils. — The  visible  mucous  membrane  of  the  nostrils  becomes 
pale  in  proportion  to  the  anemia. 

Lips  and  gums. — The  lips  also  become  pale  in  proportion  to  the 
anemia,  the  inner  surface  of  the  lips  and  the  outer  surface  of  the  gums 
frequently  presenting  almost  a  chalky  white  appearance. 

Teeth. — Irregularity  of  the  teeth  was  so  common  among  patients 
affected  with  uncinariasis  that  the  question  arose  in  my  mind  whether 
this  was  not  to  some  extent  an  expression  of  the  general  underdevel- 


67 

opment  of  the  body  due  to  this  disease.  The  point  at  issue  calls  for 
the  opinion  of  a  dentist  rather  than  that  of  a  zoologist.  The  decayed 
teeth  of  dirt  eaters  have  been  recorded  in  early  writings  on  this  habit. 

Tongue. — In  some  cases  the  tongue  was  coated.  A  number  of 
observers  have  already  called  attention  to  this  symptom,  which  was 
by  no  means  general  in  the  cases  I  observed. 

Several  authors  have  remarked  upon  the  presence  of  black,  brown, 
or  purple  spots  on  the  tongue  in  cases  of  uncinariasis,  and  the  view 
has  been  advanced  that  these  present  a  valuable  aid  in  diagnosis,  and 
in  some  cases,  at  least,  that  they  disappear  on  treatment.  In  the 
cases  which  came  under  my  observation,  I  looked  very  carefully  for 
this  symptom.  In  many  instances  I  found  more  or  less  distinct 
purplish  to  brownish  spots,  irregularly  round  or  elongate  in  shape, 
and  these  may  or  may  not  be  identical  with  the  spots  described  by  the 
authors  cited.  It  was,  however,  noticeable  that  in  many  cases  where 
these  spots  were  observed,  the  patients  were  accustomed  either  to 
chewing  tobacco  or  to  dipping  snuff.  In  fact,  some  of  the  spots  in 
question  I  am  inclined  to  refer  to  the  use  of  tobacco  or  snuff. 
Whether  all  cases  are  to  be  explained  in  this  way  is,  however,  open 
to  question,  with  probabilities  against  such  explanation.  Neverthe- 
less, it  is  well  for  practitioners  to  be  forewarned  upon  this  chance 
of  error  in  diagnosis.  Several  authors  have  assumed  that  the  spots 
on  the  tongue  represent  a  symptom  which  has  only  recently  been 
observed  in  this  disease.  In  this  connection,  it  is  interesting  to  note 
that  early  authors — for  instance,  Cragin  (1836a)  and  Imray  (1843) — in 
writing  upon  dirt-eating  have  described  these  same  spots. 

NECK. 

The  cervical  pulsations  are  often  very  evident,  and  in  some  cases 
may  be  seen  from  6  to  12  feet  away.  (See  Circulatory  system,  p.  72.) 

THORAX. 

In  emaciation  the  thorax  corresponds  to  •  the  general  emaciation  of 
the  extremities.     In  some  cases  the  ribs  are  very  prominent.. 
Heart. — See  page  72. 
Breasts. — See  page  64. 

ABDOMEN. 

"Pot-belly  "  or  "  buttermilk-belly"  dropsy,  and  tympanites. — The  con- 
dition known  as  "pot-belly"  or  "buttermilk-belly"  is  exceedingly 
common  in  uncinariasis,  especially  in  extreme  cases  in  summer.  It  is 
a  distension  of  the  abdomen,  due  apparently  to  two  factors:  (1)  a 
gaseous  distension  of  the  bowels,  and  (2)  the  presence  of  an  excess  of 
fluid  in  the  abdominal  cavity. 

I  hasten  to  add  that  I  have  not  seen  a  single  autopsy  in  man  infected 
with  uncinariasis,  but  the  same  abdominal  distention  is  found  ir 


68 

animals  suffering  from  this  disease,  and  a  number  of  post-mortem 
examinations,  especially  on  sheep,  have  given  the  conditions  described. 

Lutz  mentions  flatulence  of  the  lower  abdomen  as  a  common  symp- 
tom, and  Sandwith  (1894,  p.  11)  found  it  present  to  a  slight  extent  in 
one-third  of  the  cases. 

Hair. — See  page  64. 

GenitaUa.—SQQ  page  78. 

EXTREMITIES. 

Nothing  of  any  particular  note  was  observed  in  connection  with  the 
bones;  for  the  muscles  see  p.  73.  In  many  cases  the  feet  and  ankles 
were  swollen,  and  in  several  cases  the  legs  were  marked  with  ulcers. 
See  p.  59. 

According  to  Sandwith  (1894,  p.  12),  edema  of  the  legs,  like  albu- 
minuria,  is  to  be  seen  only  in  the  worst  cases,  and  some  of  these  had 
general  edema  when  admitted  in  a  dying  condition. 

GENITALIA. 

See  page  78. 

MUCOUS   MEMBRANES. 

All  mucous  membranes  correspond,  in  respect  to  their  color,  to  the 
grade  of  anemia.  (See  Eyelids,  p.  65;  nostrils,  p.  66;  lips  and  gums, 
p.  66;  tongue,  p.  67;  genitalia,  p.  78.) 

EXCRETIONS   AND   SECRETIONS. 


I  have  no  observations  to  record  in  regard  to  the  urine.  Sandwith 
(1894,  p.  11)  states  that— 

"The  urine  is  not  unlike  that  of  ordinary  anemia,  neutral  or  alkaline  in  equal 
proportion,  and  rarely  acid,  pale  colored,  with  specific  gravity  ranging  from  101C 
to  1015.  A  trace  of  albumen  was  present  in  all  the  most  advanced  cases,  without 
casts  under  the  microscope." 

According  to  Zinn  and  Jacoby  (1898,  p.  16),  Lussana  (1890)  found 
in  the  urine  of  patients  suffering  from  uncinariasis  a  poisonous  sub- 
stance of  the  nature  of  a  ptomaine,  which  caused  extensive  changes 
in  the  rabbit's  blood,  especially  a  change  in  the  number  of  red  blood 
corpuscles,  and  also  poikilocytosis.  These  results  are  said  to  have 
been  confirmed  by  Arslan  (1892). 

FECES. 

Consistency. — The  feces  may  be  hard  or  soft,  according  to  the  pres- 
ence of  constipation  or  diarrhea. 

Reaction. — In  reaction  the  feces  may  be  acid,  alkaline,  or  neutral. 

Color. — In  a  large  proportion  of  medium  and  severe  cases,  the  feces 
are  reddish  to  brown  in  color.  In  some  cases  blood  is  present. 


69 

Blotting  paper  test. — In  about  8  out  of  10  medium  and  severe  cases, 
if  a  portion  of  the  feces  is  placed  upon  white  blotting  paper,  and 
allowed  to  remain  there  for  twenty  minutes  to  several  hours,  it  leaves 
on  the  paper  a  reddish  brown  stain  similar  to  a  blood  stain.  This 
test  will  be  found  useful  by  physicians  who  are  not  prepared  for 
microscopic  tests. 

Microscopic  examination. — If  feces  less  than  twenty-four  hours  old 
are  examined  microscopically,  the  eggs  will  be  found  in  various  stages 
of  segmentation.  If  feces  over  twenty-four  hours  old  are  examined 
the  free  embryos  also  are  usually  found.  If  free  embryos  are  found  in 
perfectly  fresh  feces,  the  diagnosis  of  infection  with  the  worm  (Stron- 
gyloides  stercoralisa)  of  Cochin-China  diarrhea  must  be  made,  and  this 
parasite  we  may  find  in  the  same  patient  in  whom  uncinariasis  is 
present. 

CIRCULATORY    SYSTEM. 

The  symptoms  of  the  circulatory  system  are  the  most  marked  and 
most  common;  they  seem  to  develop  after  the  symptoms  of  the  diges- 
tive system,  but  before  those  of  the  nervous  system. 

ANEMIA. 

In  all  medium  and  severe  cases,  the  anemia  is  what  first  attracts 
attention.  This  varies  in  intensity  not  only  in  proportion  to  the  degree 
of  infection,  but  also  to  a  considerable  extent  in  proportion  to  the 
length  of  the  period  of  infection.  For  instance,  100  worms  may  be 
expected  to  produce  a  greater  anemia  within  a  given  time,  say  one 
year,  than  will  50  parasites.  But  50  worms  may  be  expected  to  pro- 
duce more  anemia  in  two  years  than  in  one. 

In  some  medium  cases,  the  blood  vessels  of  the  conjunctive  may  be 
more  or  less  visible,  and  the  visible  mucous  membranes  of  the  nose, 
mouth,  and  vulva,  may  be  more  or  less  of  a  normal  or  subnormal 
color.  In  the  extreme  cases,  these  structures  may  be  as  white  as 
marble  or  paper.  In  the  same  way  the  color  of  the  skin  will  vary 
(see  Skin,  p.  59;  Nails,  p.  64)  from  an  almost  natural  hue  to  a  whitish, 
lemon  yellow,  or  tan  color. 

«This  worm  is  probably  much  more  common  in  this  country  than  supposed.  The 
cases  known  to  me  to  date  are:  Baltimore,  Md. — 1  case,  1  death;  reported  by  Strong, 
1901.  Richmond,  Va. — 1  case,  0  death;  reported  by  Thayer,  1901.  Anne  Arundel 
County,  Md. — 1  case,  0  death;  reported  by  Thayer,  1901.  Washington,  D.  C. — 4 
cases,  0  death;  unpublished,  Zool.  Lab.,  U.  S.  Public  Health  and  Marine-Hospital 
Service.  Ohio — 1  case,  0  death;  unpublished,  Dr.  A.  P.  Ohlmacher  (mentioned 
here  by  kind  permission  of  the  observer).  San  Francisco,  Cal. — 3  cases,  ?  deaths; 
unpublished,  Dr.  P.  K.  Brown  (mentioned  here  by  kind  permission  of  the  observer). 
Cuba — ?  cases,  ?  deaths;  unpublished,  Dr.  John  Guiteras  (mentioned  here  by  kind 
permission  of  the  observer).  Porto  Rico — ?  cases;  ?  deaths;  unpublished,  Dr.  P.  K. 
Brown. 


70 

Blood. — I  did  not  stop  fo**  blood  counts,  as  these  have  been  made 
by  other  men,  and  while  they  are  exceedingly  interesting  from  a  path- 
ological standpoint  they  have  not  appealed  to  me  as  so  direct  a  method 
of  diagnosing  intestinal  parasites  as  is  the  fecal  examination.  In  gen- 
eral it  may  be  said  that  the  blood  of  man  corresponds  to  the  blood  of 
sheep,  goats,  cattle,  dogs,  etc.,  suffering  from  the  same  disease;  in 
other  words,  the  severer  and  longer  the  infection,  the  thinner  the 
blood.  In  the  vernacular  of  the  sandlapper,  it  is  ulike  water."  It 
may  here  be  added  that  in  early  literature  on  dirt-eating,  several 
authors  remark  upon  the  water-like  appearance  of  the  blood. 

Speaking  in  more  technical  language,  the  blood  has  been  shown  by 
Ashford  to  possess  the  following  characteristics: 

"(1)  A  severe  anemia,  falling  as  low  as  that  of  Addison's  anemia  in  count  of  red 
cells  in  some  cases.  (2)  A  very  low  hemoglobin  average  and  a  very  low  color  index. 
(3)  A  marked  eosinophilia  in  some  cases;  40  per  cent  reached  in  one  case.  This 
follows  the  observation  of  Neusser.  (4)  No  leucocytes  common  to  the  disease  itself. 
Leucocytosis  recorded  is  always  apparently  due  to  complications,  as  rioted.  (5)  Fre- 
quent presence  of  normoblasts,  and  in  some  cases  megaloblasts,  but  never  a  majority 
of  megatoblasts.  (6)  Poikilocytosis  common.  Manson  denies  this." 

Ashford  gives  the  following  interesting  table  of  blood  counts: 


71 


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72 

Cervical  pulsations. — In  the  rural  vernacular,  "jerking  at  the  neck" 
or  " jumping  at  the  neck"  refers  to  an  anemic  symptom  which  is 
exceedingly  prominent  in  most  medium  cases  and  in  all  extreme  cases 
of  uncinariasis.  It  is  simply  the  violent  pulsations  of  the  cervical 
vessels,  visible  sometimes  at  a  distance  of  2  to  4  meters. 

Heart. — Nearly  all  medium  and  severe  cases  complain  of  having 
"heart  disease"  or  a  "fluttering  of  the  heart,"  and  many  of  the 
patients  are  taking  medicine  for  this  symptom.  (See  also  p.  35.)  We 
have  here,  of  course,  the  usual  cardiac  symptoms  of  an  extreme  anemia. 

"Palpitation  over  the  heart,  in  the  epigastrium,  and  in  the  temporal  arteries  is  sure 
to  be  present  in  bad  cases,  while  the  anemic  murmurs  of  heart  and  neck  are  solely 
dependent  upon  the  degree  of  anemia,  and  can  be  banished  by  a  prolonged  course  of 
iron.  Hypertrophy  of  heart  was  noted  and  verified  after  death  in  some  of  the 
advanced  cases. ' '  (Sandwith,  1 894,  p.  12. ) 

Pulse. — Pulse  varies  from  80  to  132  per  minute.  In  medium  and 
severe  cases  I  noticed  about  120  per  minute  probably  more  frequently 
than  either  a  higher  or  a  lower  pulse.  This  was  found  in  young  and 
middle-aged  (probably  more  commonly  in  children),  in  males  and 
females,  and  yet  without  a  temperature  which  was  distinguishable  by 
the  hand  as  especially  high. 

TEMPERATURE. 

Not  being  able  to  follow  any  cases  for  any  length  of  time,  hence  not 
being  able  to  make  continued  observations  on  the  temperature,  I  con- 
sidered that  observations  in  other  lines  were  more  important  under  the 
circumstances.  Hence  I  did  not  take  temperatures  carefully.  Accord- 
ing to  observations  by  various  clinicians,  there  may  be  subnormal  or 
normal  temperature,  or  the  thermometer  may  register  100°  to  102°  F. 

"The  skin  is  always  cold,  and  the  temperature  before  thymol  generally  subnormal 
in  uncomplicated  cases.  After  excluding  any  fever  produced  by  concurrent  diseases 
and  any  defervescence  caused  by  thymol,  I  find  that  one-third  of  my  patients  had  a 
normal  temperature  during  their  stay  in  the  hospital,  but  that  two-thirds  had  a  dis- 
tinctly subnormal  range,  varying  from  an  average  of  36.3°  C.  a.  m.  to  36.9°  C.  p.  m. 

"Many  of  these  patients  when  convalescent  had  an  increase  of  half  a  degree, 
night  and  morning. 

"Surgeon-Major  Giles  suspected  that  many  of  his  patients  in  Assam  had  suffered 
from  fever  at  the  onset  of  their  malady,  and  he  was  confirmed  in  this  impression  by 
observing  pyrexia  in  the  monkeys  he  fed  on  anchylostoma  embryos.  After  elimi- 
nating all  those  who  had  fever  in  the  hospital,  or  a  history  of  intermittent  fever  or 
any  enlargement  of  the  spleen,  I  found  that  68  per  cent  of  the  remaining  stated  that 
their  trouble  had  begun  with  a  few  days'  fever."  (Sandwith,  1894,  p.  12.) 

RESPIRATORY   SYSTEM. 

NOSTRILS. 

See  page  66. 

RESPIRATION. 

Many  patients  complain  of  a  difficulty  in  breathing,  especially  after 
exertion.  This  symptom  is  quite  natural,  in  view  of  the  low  condi- 


73 

tion  of  the  blood  and  the  emaciation  of  the  muscles.  Respiration  is 
rather  variable  and  does  not  appear  to  be  a  symptom  of  very  great 
value;  it  may  be  slow,  or  it  may  be  increased  to  about  30  or  more  per 
minute.  According  to  Sandwith  (1894,  p.  12)  dyspnea  and  noises  in 
the  ears  were  present,  as  might  be  expected  with  marked  anemia. 

MUSCULAR   SYSTEM. 

EMACIATION. 

A  progressive  emaciation  is  more  or  less  common,  especially  in 
severe  cases.  The  arms  and  legs  seem  to  be  reduced  to  skin  and 
bones;  the  chest  is  so  emaciated  that  the  ribs  are  very  prominent  and 
the  beating  of  the  heart  is  very  evident.  What  little  muscle  is  left 
is  soft  and  flabby. 

Emaciation  is,  however,  not  present  in  all  cases,  and  even  in  some 
medium  infections  the  muscles  may  be  well  formed  and  more  or  less 
hard.  I  recall  one  case  in  particular:  A  boy  about  14  who  showed  a 
heavy  infection  microscopically,  a  clear  clinical  history  of  uncinariasis 
of  several  years  standing,  decided  anemia,  distinct  cervical  pulsations, 
abdomen  rather  distended  ("pot-bellied"),  yet  his  arms  and  legs  were 
well  formed  and  his  muscles  surprisingly  solid  for  a  patient  in  his  con- 
dition. 

Sandwith  (1894,  p.  13)  found  the  average  weight  of  100  grown  men 
upon  admission  to  the  hospital  to  be  117.5  pounds;  the  average  height 
of  these  men  was  5  feet  5.5  inches,  which  by  Dawson's  tables  should 
scale  at  least  135  points.  Of  the  patients  who  stayed  in  the  hospital 
more  than  two  weeks  70  per  cent  gained  weight,  22  per  cent  lost,  and 
8  per  cent  remained  stationary.  The  average  loss  of  weight  was  3.2 
pounds,  and  was,  of  course  caused  by  the  necessary  starvation,  thymol, 
and  purging.  The  average  gain  was  5.4  pounds,  some  patients  gain- 
ing as  much  as  15,  17,  18,  or  20  pounds. 


GREAT   PHYSICAL   WEAKNESS. 


One  of  the  most  pronounced  symptoms  complained  of  is  a  general 
weakness.  The  patient  states  that  he  is  obliged  to  rest  after  exer- 
tion. In  light  cases  a  feeling  of  lassitude  is  experienced  without 
being  able  to  assign  it  to  any  particular  cause;  as  a  result,  it  is  gener- 
ally assigned  by  other  people  to  laziness.  In  medium  cases  the  patient 
may  be  able  to  work  one  to  three  or  four  hours  before  becoming 
exhausted;  in  very  severe  cases  he  will  scarcely  be  able  to  walk  across 
the  room,  or  he  may  be  confined  to  the  bed  for  weeks  at  a  time. 
A  physical  examination  usually  shows  an  emaciation  proportionate  to 
the  weakness. 


74 

DIGESTIVE    SYSTEM. 

LIPS,    GUMS,    TEETH,    AND   TONGUE. 


See  p.  66. 

NAUSEA. 

Nausea  was  not  noticed.    %Sandwith  (1894,  p.  11)  states  that  vomiting 
and  nausea  are  rarely  complained  of. 


APPETITE. 


The  appetite  may  be  light  or  ravenous.  According  to  Sandwith, 
the  appetite  is  invariably  affected,  sometimes  ravenous  at  beginning, 
but  later  always  capricious  and  diminished.  The  English  nurses 
report  to  him  that  the  patients  were  always  begging  for  medical  com- 
forts or  cigarettes,  even  in  the  middle  of  the  night,  when  other 
patients  were  asleep.  Among  40  men  caref  ully  examined.  16  said  that 
their  appetite  was  once  greatly  exaggerated,  16  pleaded  diminution 
from  the  beginning  of  their  illness,  and  8  believed  that  their  appetite 
was  normal  until  the  anemia  became  very  marked. 

Perverted  appetite,  "Dirt-eating" — The  most  important  point  to  be 
noticed  in  connection  with  the  appetite  is  the  abnormal  desire  for  some 
particular  article  of  food.  Frequently  this  is  a  preference  for  some- 
thing sour  or  bitter. 

Man}'  patients  with  uncinariasis  are  known  throughout  the  village 
or  county  as  being  especially  fond  of  pickles.  1  have  seen  boys  and 
girls  in  advanced  cases  of  this  disease  who  would  greedily  devour  an 
entire  bottle  of  pickles.  Some  patients  are  especially  fond  of  sucking 
lemons,  or  lemons  and  salt,  or  salt  alone.  Others  are  known  for  their 
desire  to  chew  coffee,  or  to  drink  large  quantities  of  strong  coffee 
without  milk  or  sugar.  Some  are  abnormally  fond  of  buttermilk. 
Others  are  noted  as  "resin-chewers."  Some  are  accused  of  "  lapping 
sand."  Many  are  accused  of  eating  clay  or  dirt. 

Dirt-eating  has  been  discussed  by  a  number  of  authors,  opinion 
being  divided  as  to  its  status.  Some  writers  look  upon  it  as  the  cause 
of  the  disease;  others  view  in  the  habit  only  a  symptom  or  a  result; 
still  others  consider  it  nature's  treatment  of  a  diseased  condition. 

Among  helminthologists  there  seems  to  be  the  impression  that  dirt- 
eating  is  especially  likely  to  lead  to  infection  with  parasites.  Among 
Southern  physicians  I  found  the  idea  quite  prevalent  that  dirt-eating 
was  one  of  the  causes  of  the  condition  which  I  have  classed  as  extreme 
uncinariasis. 

During  the  trip  now  under  discussion,  I  have  had  opportunity  to 
observe  many  so-called  dirt-eaters.  As  most  authors  state,  it  is 
exceptional  that  one  will  acknowledge  that  he  eats  dirt.  1  believe  the 
explanation  of  this  denial  is  very  clear,  namely,  not  only  is  there  a 
certain  amount  of  disgrace  connected  with  the  reputation  of  being 
a  dirt-eater,  but  probably  not  over  one  person  in  ten,  or  possibly 


75 

in  twenty,  accused  of  eating  dirt  ever  does  so.  The  other  nine  to 
nineteen  have  their  abnormal  appetites  developed  in  a  different 
direction,  namely,  pickle-eating,  lemon-sucking,  coffee-chewing,  resin- 
chewing,  etc. 

Among  the  articles  eaten  by  these  "dirt-eaters,"  various  authors 
mention  charcoal,  chalk,  dried  mortar,  mud,  clay,  sand,  gravel,  stones, 
shells,  rotten  wood,  cloth,  garments,  paper,  tobacco  pipes,  mice, 
young  rats,  etc. 

It  is,  I  believe,  an  error  to  attempt  to  reduce  this  abnormal  habit  to 
any  one  common  basis.  In  general,  however,  it  may  be  stated  that 
the  alleged  "dirt-eating"  in  this  country  practically  represents  the 
severe  cases  of  uncinariasis.  To  attempt  to  reduce  dirt-eating  to 
infection  with  worms,  particularly  with  Uncinaria  americana,  will 
doubtless  be  thought  extreme,  more  particularly  by  Northern  physi- 
cians. Still  the  idea  is  not  a  new  one,  and  a  moment's  consideration 
will  show  that  this  view  is  far  less  extreme  than  it  at  first  appears. 

For  an  excellent  general  discussion  of  dirt-eating,  with  extensive 
references  to  literature,  the  reader  is  referred  to  Le  Conte  (1845). 
For  the  purpose  of  the  present  paper  it  will  suffice  to  call  attention  to 
certain  facts  and  analogies.  The  habit  of  eating  slate  pencils,  paper, 
and  other  objects  by  chlorotic  girls  is  more  or  less  commonly  known. 
Pregnant  women,  also,  may  develop  an  abnormal  appetite,  which 
takes  different  phases,  including  dirt-eating.  It  is  recorded  that  the 
Javanese  women  eat  certain  dirt  in  order  to  improve  their  appearance. 
In  certain  localities  in  tropical  America  (Orinoco)  the  natives  eat  earth 
during  the  overflow  of  the  river  when  they  can  not  obtain  their  regu- 
lar food.  Earth  eating  is  said  to  be  common  and  not  injurious  in  cer- 
tain parts  of  Africa.  According  to  Sandwith  (1894,  p.  9),  on  the  day 
of  the  maximum  high  Nile,  and  the  general  rejoicings  thereupon,  the 
town  crier,  who  is  on  the  lookout  for  backsheesh,  presents  "teen 
ibliz"  (Nile  mud)  with  a  lemon  to  the  inhabitants  for  luck,  and  many 
of  them  eat  of  it.  Dogs,  horses,  cattle,  hogs,  and  alligators  are 
recorded  as  eating  clay  and  sticks.  The  Alaskan  seals,  when  infected 
with  round  worms,  eat  pebbles.  Elephants,  when  infected  with 
flukes,  eat  a  certain  kind  of  clay  until  a  looseness  of  the  bowels  is 
produced.  I  have  frequently  heard  Texas  grangers  attribute  the 
death  of  cattle  to  eating  sand,  and  in  post-mortem  examinations  of 
cattle,  sheep,  and  goats,  in  an  anemic  condition  from  intestinal  worms 
(verminous  gastritis  caused  by  Hsemonchus  contwrtus,  H.  Ostertagi, 
etc.,  and  infection  of  small  intestine  with  Uncinaria  trigonocephala  and 
U.  radiata),  I  have  repeatedly  noticed  in  the  stomach  and  intestine 
large  quantities  of  sand;  so  that  the  farmers  present  declared  that  this 
was  the  cause  of  death.  Dogs  infected  with  intestinal  worms  eat 
grass.  Cats  also  frequently  eat  grass,  probably  from  the  same  cause. 
Children  infected  with  eel  worms  (Ascaris  lumbricoides)  are  known  to 


76 

occasionally  eat  dirt,  and  I  know  of  one  such  case  where  the  habit 
ceased  when  the  worms  were  expelled. 

In  view  of  the  comparisons  cited,  it  would  seem  that  the  idea  of 
considering  dirt-eating  as  a  manner  of  infection  with  parasitic  worms, 
although  conceivable  for  some  cases,  is  hardly  correct  as  applied  to 
most  instances.  That  dirt-eating  is  an  abnormal  appetite  due  to  a 
diseased  condition  (anemia  and  a  disordered  digestive  system)  as  sug- 
gested by  several  authors  as  early  as  the  first  half  of  last  century, 
seems  to  me  to  be  an  explanation  of  much  more  general  application; 
and  that  this  anemia  and  enteritis  or  gastritis  may  be  produced  by 
parasitic  worms  is  an  established  fact.  In  this  connection,  it  is  inter- 
esting to  note  that  Hancock  (1831,  p.  67),  in  discussing  dirt-eating, 
mentions  "worms  preventing  the  nourishing  effects  of  food;"  Imray 
(1843,  p.  310)  remarks  that  "worms  in  considerable  numbers  were  not 
uncommonly  accumulated  in  the  intestinal  canal."  Further,  it  is  sig- 
nificant that  various  authors,  in  discussing  the  treatment  of  dirt-eating, 
attribute  more  or  less  success  to  certain  drugs  which  are  in  fact  used 
more  or  less  in  treating  for  intestinal  parasites.  Thus,  Cotting  (1836a) 
refers,  as  stated  above,  to  the  decrease  of  dropsy  and  of  dirt-eating 
corresponding  to  the  more  general  use  of  calomel;  sulphate  of  iron  is 
mentioned  by  Cragin  (1836a),  Pollard  (1852),  and  others;  according  to 
Pollard  (1852),  copperas  is  a  popular  and  successful  remedy  among 
the  negroes;  Hancock  (1831)  refers  to  a  remedy  containing  arsenic 
as  having  had  great  success;  Jordan  (1832)  states  that  dirt-eating 
decreased  upon  destroying  the  huts  and  moving  the  families  to  some 
other  location. 

To  summarize:  While  it  would  seem  decidedly  extreme  and  unwar- 
ranted to  maintain  that  dirt-eating  is  necessarily  an  indication  of 
infection  with  intestinal  worms,  still  I  believe  the  conclusion  is  justi- 
fied that  it  is  undoubtedly  a  more  or  less  common  tendency  in  such 
infections,  not  only  in  man  but  also  in  other  animals.  It  may  be 
classed  with  the  chewing  of  slate  pencils,  resin,  coffee,  sucking  of 
lemons  and  salt,  etc. ,  as  an  abnormal  appetite  due  to  the  anemia  and 
abnormal  condition  of  the  intestinal  tract.  Further,  for  all  practical 
purposes  it  is  not  much  of  an  exaggeration  to  look  upon  most,  if  not 
all,  so-called  dirt-eaters  of  the  sand  areas  of  our  Southern  States  as 
representing  severe  cases  of  uncinariasis. 

Sandwith  (1894)  states  that  26  per  cent  of  his  patients  confessed  to 
eating  earth,  and  he  refers  to  "earth  hunger"  as  sometimes  the  cause 
and  sometimes  the  effect  of  hookworm  disease. 

PAIN  IN  THE  STOMACH;  INDIGESTION. 

Many  patients  complain  of  colicky  pains  "in  the  stomach,"  and 
will  indicate  the  region  between  the  navel  and  the  ensiforni  cartilage 
as  the  seat  of  the  "misery."  Indigestion  is  frequently  mentioned, 
and  the  tongue  is  occasionally  coated. 


77 

Just  how  much  the  indigestion  is  due  to  uncinariasis  and  how  much 
to  other  causes  may  be  considered  an  open  question.  Foul  breath  is 
mentioned  by  some  authors  as  a  common  symptom  of  uncinariasis,  but 
this  has  not  been  particularly  noticeable  in  many  of  the  cases  I  saw. 

Many  authors  explain  the  tendency  to  dirt-eating  as  an  effort  to  neu- 
tralize the  hyperacidity  of  the  stomach.  As  1  have  just  shown  (p.  74), 
however,  many  patients  with  uncinariasis  eat  pickles  and  suck  lemons. 

According  to  Sand  with,  a  gnawing,  throbbing  pain  in  the  epigas- 
trium is  the  first  symptom  complained  of,  chiefly  because  it  is  constant, 
whereas  a  severe  colic  and  borborygmi  (rumbling  of  bowels  caused  by 
gas)  of  intestine  are  present  from  time  to  time.  1  was  unable  to  con- 
firm the  constancy  of  the  pain. 


CONSTIPATION   AND   DIARRHEA. 


Sandwith  (1894,  p.  11)  states  that  when  the  patient  is  not  under 
thymol  and  purgative  treatment,  constipation  is  a  very  constant  symp- 
tom in  hospital  cases;  60  per  cent  had  suffered  for  a  long  time  from 
obstinate  constipation,  28  per  cent  had  had  diarrhea  before  admission, 
and  12  per  cent  had  no  recollection  of  being  troubled  with  either. 
"  None  of  the  figures  depending  upon  the  memory  of  the  patients 
must  be  taken  as  absolute  truth,  as  the  intelligence  of  many  is  of  a 
very  low  order."  Diarrhea,  and  even  dysentery,  are  not  uncommon 
in  very  advanced  cases,  especially  those  complicated  with  Bilharzia 
(—  Schistosoma,  which  has  not  been  reported  as  endemic  in  the  United 
States),  or  ulceration  in  the  rectum;  and  unless  the  patient  is  robust 
enough  to  support  thymol,  such  cases  are  apt  to  end  fatally. 

In  my  own  cases  I  found  both  constipation  and  diarrhea,  but  I  am 
not  in  a  position  to  state  that  either  symptom  was  regular  or  charac- 
teristic for  any  given  degree  or  stage  of  infection.  In  severe  cases 
diarrhea  was  certainly  more  or  less  common. 

Feces. — See  page  68. 

NERVOUS   SYSTEM. 

The  nervous  s}^mptoms  usually  develop  later  than  either  the  intes- 
tinal or  the  circulatory  symptoms. 

EYES. 

See  page  65. 

EARS. 

According  to  Sandwith  (1894,  p.  12),  noises  in  the  ear  are  present. 
None  of  my  patients  complained  of  this  symptom. 

MENTAL   LASSITUDE,    HEADACHE,    DIZZINESS,    AND   NERVOUSNESS. 

Not  only  does  physical  exertion  result  in  exhaustion,  but  mental 
exertion  has  to  be  avoided.  The  children  complain  that  they  are 
unable  to  study  and  that  any  continued  application  to  books  results  in 


78 

severe  headache.  This  feature  of  the  disease  is  fully  confirmed  by 
the  testimony  of  both  teachers  and  parents,  who  assert  that  children 
of  this  class  are  usually  much  more  backward  (and  even  stupid  in 
their  studies)  than  other  children  not  showing  the  symptoms  under 
discussion. 

Dizziness  is  very  commonly  mentioned  by  the  patients.  This  feel- 
ing, which  they  usually  speak  of  as  a  "swimming  in  the  head,"  is 
experienced  especially  upon  rising  suddenly  from  a  chair  or  a  bed. 

Nervousness  does  not  seem  to  be  so  commonly  complained  of  as 
mental  lassitude,  headache,  and  dizziness.  Still  it  is  more  or  less  fre- 
quently mentioned,  more  particularly  by  the  girls  and  women. 

Among  girls  from  about  13  to  20  years  of  age  it  was  quite  notice- 
able that  they  were  more  timid  and  more  emotional  than  were  their 
healthier  sisters. 

According  to  Sandwith  (1894,  pp.  11-12),  there  is  pain  in  the  head, 
generally  referred  to  the  temples,  while  in  the  knees  there  is  almost 
invariably  present  great  weakness  and  some  pain;  occasionally  there 
is  in  addition  pain  in  the  shoulders.  Giddiness  is  another  very  gen- 
eral symptom,  and  it  is  this  as  much  as  anything  else  which  compels 
the  patients  to  give  up  work.  The  worst  cases  are  those  which  are 
nearly  always  asleep,  and  can  not  be  interested  in  anything  when  they 
are  awake.  On  the  whole,  sleepiness  is  decidedly  a  symptom.  Dense 
stupidity,  associated  sometimes  with  reiterated  demands  for  a  favor 
already  granted,  shows  that  the  bloodless  brain  is  affected  in  all 
advanced  cases,  and  at  least  three  times  Sandwith  (1894,  p.  13)  found 
a  condition  of  weak-mindedness  which  would  have  warranted  the 
patients  being  sent  to  the  asylum. 

PATELLAE   REFLEX. 

Absence  of  patellar  reflex  is  reported  in  cases  of  general  debility 
and  muscular  weakness.  Sandwith  (1894,  p.  13)  found  this  reflex 
unaltered  in  35  per  cent  of  the  cases  examined,  completely  absent  in 
48  per  cent,  decidedly  diminished  in  5  per  cent,  and  a  little  exagger- 
ated in  12  per  cent,  all  of  which  were  early  cases. 

GENITAL   SYSTEM. 

EXTERNAL   GENTTALIA;    SEXUAL   FUNCTION;    MENSTRUATION;    STERILITY. 

In  cases  where  infection  has  taken  place  in  early  childhood,  the 
delayed  development  of  the  genital  S3Tstem  is  very  marked.  Patients 
of  16  to  22  years  of  age  may  not  be  better  developed  than  healthy  per- 
sons of  11  to  15  years.  Menstruation  may  be  very  irregular,  espe- 
cially in  summer.  This  same  condition  is  insisted  upon  in  many  early 
writings  on  dirt-eating.  Mothers  frequently  ascribe  the  condition  of 
their  daughters  to  the  absence  or  irregularity  of  the  menstruation  as 
is  mentioned  also  in  early  writings  on  dirt-eating. 


79 

Sandwith  (1894,  p.  13)  found  impotence  to  be  a  decided  symptom  in 
hookworm  disease.  Of  38  men  especially  examined  on  this  point,  24 
had  completely  and  5  had  almost  entirety  lost  their  virile  power, 
while  of  the  remaining  9  men,  5  aged  from  19  to  25  had  their  puberty 
considerably  delayed. 


TENDENCY   TO   ABORTION. 


Among  women  affected  with  uncinariasis  I  found  a  marked  tend- 
ency to  abortion.  Given  a  woman  about  28  years  old  who  had  been 
married  nine  years — a  not  uncommon  history  is  that  she  has  had  3  to 
5  children  and  3  to  4  miscarriages,  and  she  looks  to  be  about  50  }^ears 
old.  Not  being  able  to  follow  these  cases  through  their  entire 
medical  history  and  the  history  of  their  husbands,  I  must  leave  the 
question  open  as  to  how  many  of  these  abortions  are  to  be  attributed 
to  uncinariasis  and  how  many  are  due  to  other  causes.  In  the  country 
districts  I  was  thrown  in  with  the  anemic  not  with  the  healthy 
families,  hence  1  have  no  good  basis  for  comparison  of  these  two 
classes  for  the  particular  localities  visited.  In  some  cases  a  history 
of  venereal  disease  was  suspected  or  admitted;  in  others,  the  abortion 
came  on  after  pitching  fodder;  in  some  cases  the  patients  had  taken 
more  or  less  quinine  during  their  life,  under  the  supposition  that  they 
had  malaria;  and  in  still  other  cases,  my  suspicions  were  aroused  in 
other  directions.  The  determination  of  the  exact  relation  of  uncina- 
riasis to  the  miscarriages,  which  are  certainly  strikingly  prevalent, 
must  be  left  to  those  who  can  follow  the  cases  for  a  longer  period  of 
time. 

PREVALENCE    OF   UNCINARIASIS   IN   THE   UNITED   STATES. 

In  several  earlier  papers  (1901,  p.  524;  1902  a,  p.  778;  1902  b,  pp.  183, 
212)  I  have  advanced  the  view  that  uncinariasis  must  be  more  common 
in  this  country  than  is  generally  supposed.  In  my  preliminary  report 
on  this  trip  (see  above,  p.  35),  I  said  that:  "There  is  in  fact  not  the 
slightest  room  for  doubt  that  uncinariasis  is  one  of  the  most  impor- 
tant and  most  common  diseases  of  this  part  [South  Carolina]  of  the 
South,  especially  on  farms  and  plantations  in  sandy  districts." 

Harris  (see  above,  p.  36)  went  even  farther  than  this  and  claimed 
that  uncinariasis  is  "the  most  common  of  the  severe  diseases  of  the 
South." 

In  considering  the  subject  of  the  frequency  and  economic  impor- 
tance of  the  disease  under  discussion,  I  do  not  wish  to  seem  to  under- 
estimate the  prevalence  of  tuberculosis  and  of  venereal  diseases  among 
the  negroes  or  of  malaria  among  the  whites.  Further,  I  recognize 
the  fact  that  at  the  present  moment  an  exact  mathematical  estimate 
can  not  be  made.  Speaking  in  general  terms,  however,  the  facts  at  my 
disposal  at  present  seem  to  indicate  that  taking  the  Southern  Atlantic 


80 

States  as  a  whole,  uncinariasis  must  be  considered  as  one  of  the  most 
common  and  widespread  maladies;  in  frequency  it  belongs  in  the 
general  class  with  malaria,  tuberculosis,  and  gonorrhea. 

In  cities  and  in  rural  clay  districts  it  is  probably  less  common  than 
any  one  of  these  three  maladies,  for  such  localities  may  present  local 
foci  of  infection  for  the  diseases  in  question,  while  the  local  foci  of 
infection  with  uncinariasis  are  much  more  limited. 

Among  the  negroes  of  the  rural  sand  districts,  uncinariasis  seems  to 
be  much  less  common  than  either  tuberculosis  or  gonorrhea.  Its 
apparent  rarity  may,  however,  be  deceptive  (see  p.  51). 

Among  the  whites  of  the  rural  sand  districts,  uncinariasis  is  appar- 
ently the  most  common  disease  found.  Nevertheless,  in  some  sand 
districts,  probably  with  a  clay  or  other  impervious  subsoil  favorable 
to  the  formation  of  marshes,  malaria  rivals  uncinariasis  for  first  place. 

From  these  qualified  statements  it  will  be  seen  that  I  do  not  feel 
justified  in  adopting  the  view  advanced  by  Harris,  namely,  that  uncin- 
ariasis is  athe  most  common  of  the  severe  diseases  of  the  South." 

In  all  probability,  further  study  will  show  that  in  Mexico,  Central 
America,  and  parts  of  South  America,  hookworm  disease  is  more 
important  and  more  common  than  in  the  United  States. 

Sandwith  (1894,  pp.  5-6),  in  discussing  the  frequency  of  this  disease 
in  Egypt,  says : 

"It  is  impossible  to  know  what  amount  of  the  population  [of  Egypt]  is  affected, 
but  the  statistics  of  the  recruiting  commissioners  for  1892  are  worth  quoting.  Nearly 
every  adult  male  peasant  is  liable  for  conscription,  and  the  conscripts  are  immedi- 
ately examined  in  their  villages.  In  upper  Egypt  5,988  men  were  called,  and  200, 
or  3.3  per  cent,  were  rejected  for  anaemia.  In  lower  Egypt  661,  or  6.2  per  cent  were 
rejected  from  this  cause  out  of  7,420  men.  Every  province  furnished  anaemic  rejec- 
tions, but  Menoufieh  came  highest  on  the  list  with  13.9  per  cent,  while  I  find  from 
hospital  statistics  that  no  less  than  15  villages  in  that  province  are  infected.  The 
recruiting  medical  officer,  who  is  an  Englishman,  only  rejects  those  who  are  obvi- 
ously too  anaemic  to  serve  with  the  colors,  accepting  many  who  are  already  the 
hosts  of  the  bloodsucking  worm.  Thus  the  medical  reports  for  the  Egyptian  army 
show  that  in  1890  there  were  114  admissions  to  the  hospital  for  anaemia,  in  1891,  107 
admissions,  and  in  1892,  170  admissions.  In  1891,  22  soldiers  were  invalided  from  the 
service  for  anaemia,  and  65  in  1892,  besides  1  death.  The  number  of  admissions  for 
debility  is  equal  to  those  for  ansemia,  and  doubtless  includes  many  cases  of  anchy- 
lostomiasis." 

Dobson  (1893,  p.  63),  examined  547  of  the  healthiest  looking  coolies 
from  India  and  found  hookworms  in  no  less  than  454  of  them. 

CLINICAL   DIAGNOSIS   OF   HOOKWORM   DISEASE. 

As  stated  above,  a  man  who  is  familiar  with  this  disease  should 
have  no  difficulty  in  recognizing  severe  cases,  especially  if  he  is  in  the 
area  of  infection.  In  light  and  medium  cases,  however,  it  is  unsafe  to 
make  a  diagnosis  upon  symptoms  alone,  unless  such  cases  are  associated 


81 

in  the  same  family  or  neighborhood  with  severe  cases.  The  best  and 
most  reliable  method  of  diagnosis  is  by  fecal  examination,  although  in 
blood  examination  increased  eosinophilia  indicates  the  possibility  of 
intestinal  parasites. 

First  of  all  let  us  recall  that  uncinariasis  is  a  possibility  which  should 
be  considered  in  connection  with  all  cases  of  anemia,  especially  among 
earthworkers,  as  in  miners,  brickmakers,  canal  diggers,  farmers,  etc., 
or  in  persons  returning  from  the  tropics,  and  among  persons  who  have 
a  history  of  residence  on  sandy  soil.  Three  methods  of  fecal  examina- 
tion are  open  to  us — the  blotting-paper  test  and  the  microscopic  and 
the  gross  examinations. 


BLOTTING   PAPER   TEST   WITH    FECES. 


For  persons  who  are  not  in  a  position  to  make  a  microscopic  exami- 
nation, the  blotting-paper  test  (referred  to  on  p.  69),  will  be  found 
very  useful.  To  make  the  test,  use  only  fresh  feces.  Place  an  ounce 
or  more  of  the  stool  on  a  piece  of  white  blotting  paper  (any  absorbent 
white  paper  will  answer  the  purpose);  allow  it  to  stand  for  twenty  to 
sixty  minutes;  remove  the  feces  and  examine  the  color  of  the  stain. 
In  about  four  out  of  five  cases  of  medium  or  severe  uncinariasis,  the 
stain  is  reddish  brown  and  immediately  reminds  one  of  a  blood  stain. 
In  making  this  test  on  anemic  patients,  piles  should  of  course  be 
excluded. 

It  developed  in  my  work  in  the  Virginia  penitentiary,  that  this  test 
is  open  to  error  in  dealing  with  criminals.  In  order  to  avoid  work, 
convicts,  especially  hard-labor  contract  convicts,  occasionally  produce 
a  hemorrhage  purposely  by  wounding  the  mucosa  of  the  rectum  by 
means  of  some  sharp  instrument. 

19558— No.  10—03 6 


82 


7-1 


FIG.  43.— Egg  of  the  common  ascaris  (Ascaris  lumbricoides)  of  man,  as  found  in  feces.    Seen  with 

superficial  focus.    Greatly  enlarged.     (After  Stiles,  1902b,  p.  202,  fig.  158.) 

FIG.  44.— The  same,  as  seen  with  median  focus.    Greatly  enlarged.    (After  Stiles,  1902b,  p.  202,  fig.  159.) 
FIGS.  45-54. — Embryology  of  the  common  ascaris  (Ascaris  lumbricoidca)  of  man,  showing  the  changes 

undergone  by  the  egg  after  being  discharged  in  the  feces.     (After  Leuckart,  1867,  p.  213,  fig.  154.) 
FIG.  55.— Embryo   of  the  common  ascaris  (Ascaris  lumbricoides)  of  man,  in  the  eggshell.    (After 

Leuckart,  1867,  p.  215,  fig.  156.) 
FIG.  56. — Free  embryo  of  the  common  ascaris  (Ascaris  lumbricoides)  of  man,  casting  its  skin.    (After 

Leuckart,  1867,  p.  214,  fig.  155.) 
FIGS.  57-64.— Embryology  of  the  common  pinworm  (Ori/uris  rermicularis)  of  man,  showing  the  changes 

undergone  by  the  egg  while  in  the  female  worm.     (After  Leuckart,  1868,  p.  322,  fig.  191. ) 
FIG.  65. — Embryo  of  the  common  pinworm  (O-Jcyuris  vermicularis)  of  man,  in  the  eggshell,  as  found  in 

fresh  feces.     (After  Leuckart,  1868,  p.  328,  fig.'  196.) 
FIG.  66. — Full-grown  embryo  of  the  common  pinworm  (O.i-i/tirix  rermicularis)  of  man,  after  it  has 

escaped  from  the  eggshell.     (After  Leuckart,  1868,  p.  328,  fig.  195.) 
FIGS.  67-70.— Egg  of  the  common  whipworm  (  THchuris  tricliiura)  of  man,  showing  changes  undergone 

while  still  in  the  female  worm;  fig.  70  is  the  stage  found  in  fresh  feces.     (After  Leuckart,  1868, 

p.  491,  fig.  275.) 
FIGS.  71-73. — Later  stages  of  development  of  an  allied  whipworm  (Tri<-fni.rix  « [tin  is)  of  sheep  and 


FIG 


cattle,  showing  changes  after  the  egg  escapes  in  the  feces.     (After  Leuckart,  18(i8,  p.  494,  fig.  276.) 
.  74.— Isolated  embryo  of  Trichuris  affinis.     (After  Leuckart,  1868,  p.  495,  fig.  277.) 


83 


FIG.  75.— Egg  of  Cochin-China  diarrhea  worm  (Strongyloides  stercoralis)  found  in  stools.   (After  Thayer, 

1901,  pi.  9,  fig.  A.) 

FIG.  76.— Rhabditiform  embryo  of  same,  from  the  stools.     (After  Thayer,  1901,  pi.  9,  fig.  B.) 
FIG.  77. — Filariform  larva  of  same  derived,  by  direct  transformation,  from  a  rhabditiform  embryo. 

(After  Thayer,  1901,  pi.  9,  fig.  C.) 

Figures  75  to  77  were  drawn  from  life,  as  seen  under  Leitz,  objective  7— ocular  3. 


o— . 


FIG.  78.— Egg  of  the  common  liver  fluke  ( Fasciola  hepatica}  examined  shortly  after  it  was  taken  from  the 

liver  of  a  sheep;  this  is  the  same  stage  that  is  found  in  human  feces;  at  one  end  is  seen  the  lid  or  opercu- 

lum,  o;  near  it  is  the  segmenting  ovum ;  the  rest  of  the  space  is  occupied  by  yolk  cells  which  serve  as 

food ;  all  are  granular,  but  only  three  are  thus  drawn.    X  680.    (After  Thomas,  1883,  p.  281,  fig.  1.) 
FIG.  79.— Egg  of  the  common  liver  fluke  containing  a  ciliated  embryo  (miracidium)  ready  to  hatch 

out;  d,  remains  of  food;   e,  cushion  of  jelly-like  substance;  /,  boring  papilla;  h,  eye-spots;  k, 

germinal  cells.     X  680.     (After  Thomas,  1883,  p.  283,  fig.  2. ) 
FIG.  80.— Embryo  of  the  common  liver  fluke  (Fasciola  hepatica)  boring  into  a  snail.     X  370.    (After 

Thomas,  1883,  p.  285,  fig.  4.) 
FIG.   81. — Egg  of  lancet  fluke  (Dicroccclium  lanccatnm)  with  contained  embryo.     X  700.     (After 

Leuckart,  1889,  p.  379,  fig.  171.) 
FIG.  82.— Egg  of  human  blood  fluke  (Schistosoma  h.rmatobium)  with  contained  embryo,  passed  in  the 

urine  or  in  the  feces.    X  285.    (After  Looss,  1896,  pi.  11,  fig.  112.) 
FIG.  83.— Egg  of  beef-measle  tapeworm  (Tfenia  saginata)  with  thick  eggshell  (embryophore),  con-: 

taining  the  six-hooked  embryo  (oncosphere)  enlarged.    (After  Leuckart.) 
FIG.  84.— Eggs  of  pork-measle  tapeworm  (Ttrnia  solinni):  a,  with  primitive  vitelline  membrane;  b, 

without  primitive  vitelline  membrane,  but  with  striated  embryophore.    X  450.    (After  Leuckart, 

1880,  p.  667,  fig.  297.) 


85 

MICROSCOPIC    EXAMINATION    OF    FECES. 

No  special  technique  is  necessary.  Simply  take  a  small  amount  of 
;f  eces,  preferably  from  near  the  surface,  about  the  size  of  the  head  of  a 
large  pin;  spread  this  out  in  a  drop  of  water  on  an  ordinary  micro- 
Lscopic  slide  and  cover  the  preparation  with  a  cover  slip.  Examine 
under  any  moderately  high  power,  as  a  Zeiss  8  mm.,  Zeiss  C,  or  a 
Biiusch  &  Lomb  one-third  inch.  Look  carefully,  with  not  too  strong 
illumination,  for  an  elongate  oval  egg  with  thin  shell,  and  with  proto- 
plasm either  unsegmented  or  in  the  early  stages  of  segmentation.  -The 
older  the  f  eces  and  the  warmer  the  weather  the  more  advanced  will  be 
the  segmentation.  In  case  of  infection  with  Uncinaria  americana  the 
fully  developed  embryo  may  be  found  within  the  eggshell.  Be  cau- 
tious not  to  mistake  for  the  egg  of  the  Uncinaria  the  eggs  of  Ascaris 
lunibricoides,  which  have  a  thick  gelatinous,  often  mammillated, 
covering  and  an  unsegmented  protoplasm  (figs.  43-44),  or  the  eggs 
(figs.  57-65,  of  Oxyuris  vermicularis,  with  a  thin 
asymmetrical  shell  (one  side  being  almost  straight) 
and  containing  an  embryo,  or  the  eggs  of  whip- 
worms  (Trichuris  trichiura,,  more  commonly  known 
to  physicians  as  Trichocephah^s  dispar),  possessing  a 
smooth,  thick  shell,  apparently  perforated  at  each 
pole,  and  an  unsegmented  protoplasm  (fig.  70). 

As  a  rule,  in  fecal  examination  I  prefer  to  use  the 

,  ,  .    ,      ,  _    ,         _    .      ,       ,  .  -,  r,  .  ,    .         FIG.    85.—  Egg    of    the 

thick,  large,  2  by  3  inch  slide,  such  as  is  used  in       dwarf  tapeworm  (fly- 


examining-  for  trichinae,  rather  than  the  ordinary  1       ^enoiepis    nana)    of 

•u      oil,-      u  T?       v   u      i-j      «      rnu      l  VJ      •  man-    Greatly  magni- 

by  3  thin     English  slide."     The  larger  slide  is  not       fled.  (  After  B.H.Ran- 


only  more  steadily  and  more   easily  manipulated       som' 

in  case  one  is  working  without  a  mechanical  stage,  but  it  is  much 

cleaner  to  handle. 

In  most  cases  of  infection  with  intestinal  worms  the  simple  method 
just  described  will  suffice  for  a  positive  diagnosis.  Before  giving 
a  negative  opinion,  however,  I  invariably  make  ten  preparations 
or  follow  a  procedure  which  we  may  call  "  sedimenting  the  feces." 
Experience  has  shown  me  that  in  cases  of  negative  diagnosis  by  the 
simple  method  positive  diagnosis  occasionally  results  if  the  feces  are 
washed  and  "  sedimented." 

Method  of  washing  and  sedimenting  feces.—  -Take  one  or  two  ounces 
of  feces,  fresh  or  dry,  mix  with  water,  and  place  in  a  large  bottle, 
retort,  jar,  or  any  other  receptacle;  add  enough  water  to  make  from  a 
pint  to  two  quarts,  according  to  the  amount  of  feces;  shake  or  stir 
thoroughly  and  allow  to  settle;  pour  off  the  floating  matter  and  the 
water  down  to  near  the,  sediment;  repeat  the  washing  and  settling 
several  times,  or  as  long  as  any  matter  will  float.  The  last  time  this  is 
done  use  a  bottle  or  graduate  with  a  smaller  diameter,  and  when  the 
material  is  thoroughly  settled  examine  the  fine  sediment.  It  will  be 


86 

found  that  the  eggs  have  settled  more  numerously  iathe  fine  sediment 
than  in  the  coarse  material. 

In  case  an  unusual  amount  of  large  coarse  material  is  present  in  the 
feces,  it  is  sometimes  convenient  to  pour  the  entire  mass  through  a 
sieve,  rejecting  the  portion  left  in  the  sieve;  or  to  wash  the  feces  in  a 
sieve,  holding  the  latter  under  water.  As  a  rule,  however,  the  sieve 
is  not  very  useful  in  fecal  examinations. 

The  centrifuge  does  not  appear  to  be  of  any  special  value  in  fecal 
examinations. 

If  facilities  are  not  at  hand  for  making  a  microscopic  examination, 
about  half  an  ounce  of  either  perfectly  fresh  feces,  or  of  rather  dry 
feces,  may  be  placed  in  a  bottle,  preferably  with  a  large  neck,  prop- 
erly packed  in  a  mailing  case,  and  sent  to  any  professional  pathologist 
or  zoologist  for  examination. 


GROSS   EXAMINATION   OP   PECES. 


If  uncinariasis  is  suspected  and  it  is  not  practicable  either  to  make 
a  microscopic  examination  or  to  delay  matters  until  a  specimen  can  be 
sent  away  for  examination,  still  another  method  of  diagnosis  is  possi- 
ble. Give  a  small  dose  of  thymol,  followed  by  salts,  and  collect  all  of 
the  stools  passed.  Wash  the  stools  thoroughly  several  times  in  a 
bucket,  and  examine  the  sediment  for  worms  about  half  an  inch  long, 
about  as  thick  as  a  hairpin  or  hatpin,  and  with  one  end  curved  back  to 
form  a  hook.  If  these  are  found,  institute  definite  treatment. 

TREATMENT    OF   HOOKWORM    DISEASE. 


ANTHELMINTHIC   TREATMENT. 


The  two  drugs  most  commonly  used  in  uncinariasis  are  thymol  and 
male  fern.  The  day  before  treatment  the  patient  is  placed  on  a  milk 
and  soup  diet  for  three  days. 

Thymol. — The  directions  usually  given  for  thymol  treatment  are 
these:  Two  grams  (31  grains)  of  thymol  at  8  a.  m. ;  2  grams  (31  grains) 
at  10  a.  m. ;  castor  oil  or  magnesia  at  12  noon. 

One  week  later  the  stools  should  be  examined,  and  if  eggs  are  still 
present,  treatment  should  be  repeated  until  the  eggs  disappear,  but  it 
is  not  best  to  give  the  thymol  more  than  one  day  per  week.  Some 
cases  of  hookworm  disease  are  quite  obstinate  and  require  a  treatment 
extending  over  several  weeks.  It  is,  therefore,  an  unfortunate  error 
to  expel  a  few  worms  with  one  or  two  doses  and  then  dismiss  the 
patient  as  cured  without  having  made  further  microscopic  examination 
for  eggs. 

Sandwith  (1894,  p.  21)  reports  42  men  cured  after  a  single  dose;  58 
after  2  doses;  43  after  3  doses;  25  after  4  doses;  9  after  5  doses;  4 
after  6  doses;  2  after  7  doses,  and  2  after  8  doses. 


A  number  of  writers,  particularly  Giles,  Sandwith,  and  others, 
agree  that  small  doses  of  thymol  are  valueless,  but  Sandwith  is  of  the 
opinion  that  4  grams  in  24  hours  are  as  efficacious  as  6  grams,  and  the 
former  dose  is  certainly  less  dangerous. 

Worms  may  be  found  in  the  stools  as  early  as  eight  hours  after  the 
first  dose  of  thymol.  In  50  cases  Sandwith  counted  1,301  worms  in 
stools  passed  within  eight  hours  after  the  first  dose  and  444  worms 
within  the  next  sixteen  hours.  From  his  context,  however,  it  is  clear 
that  brandy  was  given  to  these  patients  (see  below),  hence  the  thymol 
was  dissolved  more  rapidly.  Giles  reports  that  he  seldom  found  any 
worms  until  twelve  hours  after  the  first  dose  of  thymol.  "Occasion- 
ally patients  vomited  after  swallowing  thymol,  but  as  a  rule  they 
retained  it  perfectly,"  and  uthey  used  to  ask  for  an  extra  dose  of  it 
while  convalescing. " 

Sandwith  goes  on  to  say  that  "large  doses  of  thymol  have  a  poison- 
ous effect  on  the  system,  not  unlike  those  produced  by  carbolic  acid. 
The  temperature  is  lowered  one  or  even  two  degrees  centrigrade,  and 
both  pulse  and  respiration  are  slowed.  The  patient  remains  fora  few 
hours  collapsed,  giddy,  and  faint,  and  has  to  be  kept  lying  down,  but 
at  sunset  he  is  quite  well  again  and  asking  for  food."  He  gives  the 
following  as  a  typical  case: 

"January  14,  1892. — 6  a.  m.,  temperature  37.5°,  pulse  80,  respiration  19;  patient  in 
his  usual  state  and  was  given  2  grams  of  thymol.  7  a.m.,  temperature  37°,  pulse 
80,  respiration  19;  says  he  has  slight  nausea,  giddiness,  and  colicky  pains  in  the 
epigastrium.  8  a.m.,  2  grams  more  of  thymol  given.  9  a.m.,  temperature  35.5°, 
pulse  70,  respiration  17;  great  giddiness,  can  not  stand  or  walk;  very  sleepy,  and 
talks  like  a  drunken  or  very  sleepy  man.  12  a.  m.,  symptoms  much  the  same;  sweat- 
ing while  asleep.  2  p.m.,  temperature  37.5°,  pulse  75,  respiration  18;  apparently 
quite  wrell  again.  Says  he  does  not  mind  the  thymol,  except  that  it  makes  him  lose 
consciousness. ' ' 

Some  authors  advise  the  use  of  alcohol  with  thymol,  others  warn 
against  such  use.  Sandwith,  in  referring  to  this  subject,  says: 
"Warned  by  the  death  of  at  least  one  of  my  patients  immediately 
after  digesting  the  thymol,  I  have  always  administered  to  feeble  men 
25  grams  of  brandy  with  each  2  grams  of  thymol,  with  the  happiest 
results." 

Authors  who  warn  against  the  use  of  alcoholics  during  treatment  do 
so  on  the  ground  that  thymol  is  soluble  part  for  part  in  alcohol,  hence 
will  more  quickly  be  absorbed  by  the  system.  With  one  of  my  assist- 
ants (see  Stiles  &  Pfender,  1902a),  in  the  Bureau  of  Animal  Industry, 
I  treated  a  number  of  dogs  with  thymol  in  various  forms.  We  gave 
doses  varying  from  10  to  100  grains  (0.648  to  6.48  grams)  to  dogs 
weighing  from  8  to  35  pounds.  In  alcoholic  solution,  30  grains  (1.94 
grams)  caused  convulsions  in  a  dog  weighing  15  pounds,  and  severe 
convulsions  in  one  weighing  14  pounds;  on  the  other  hand,  an  8-pound, 
old  dog  suffered  no  ill  effects  after  30  grains  in  alcohol,  and  a  35-pound 


88 

dog  took  75  grains  (4.86  grams)  in  alcohol  without  deleterious  effect. 
In  tablet  form,  without  oil,  a  single  dose  of  100  grains  (6.48  grams) 
killed  a  dog  of  15  pounds  in  four  days;  a  dose  of  50  grains  caused  a 
12-pound  dog  to  attempt  to  vomit;  a  dose  of  75  grains  was  without 
appreciable  effect  in  a  dog  of  35  pounds;  30  grains  were  without  effect 
on  a  dog  of  8  pounds;  daily  doses  of  20  grains  each  caused  a  slight 
diarrhea  after  six  days  in  a  dog  of  15  pounds;  the  same  dose  caused  a 
17-pound  dog  to  be  quite  sick  on  the  sixteenth  day.  In  tablet  form, 
with  castor  oil,  30  grains  caused  a  12-pound  dog  to  attempt  to  vomit, 
while  doses  of  10  and  20  grains  were  negative  on  dogs  weighing  12  to 
15  pounds.  In  powdered  form,  without  oil,  20  grains  caused  a  12- 
pound  dog  to  attempt  to  vomit,  while  doses  of  10  and  20  grains  respec- 
tively were  negative  in  dogs  of  12  and  15  pounds;  40  grains  .caused  no 
ill  effects  in  a  dog  of  8  pounds,  and  a  dose  of  80  grains  was  without 
effect  on  a  dog  of  35  pounds.  In  powdered  form,  with  castor  oil,  20 
grains  caused  slight  convulsions  in  a  dog  weighing  15  pounds,  but 
doses  of  10  and  20  grains  were  negative  on  dogs  of  the  same  weight. 
Blue  foxes  to  which  we  gave  3  grains  in  alcohol  became  quite  sick. 
Theobald  states  that  a  dose  of  3  grains  has  produced  partial  prostra- 
tion in  a  bull-terrier,  but  he  does  not  give  the  weight  of  the  dog. 

According  to  Sand  with,  the  contra-indications  for  thymol  are  "  excess- 
ive debility,  very  low  temperature,  age  above  60,  and  advanced  diseases 
of  the  heart  or  any  other  organ.  Boys  take  it  very  well  in  half  quan- 
tities." 

Sandwith  states  (1894,  p.  17),  that  of  8  fatal  cases  treated  with 
thymol  2  died,  he  thinks,  in  consequence  of  the  thymol,  eleven  and 
forty -eight  hours,  respectively,  after  taking  the  dose;  both  of  these 
men  had  previously  had  thymol  without  bad  effect,  but  they  were 
both  in  a  miserable  state  of  exhaustion  and  debility.  He  does  not 
think  that  thymol  accelerated  the  deaths  of  any  of  the  remaining  6 
cases,  which  occurred  five,  six,  nine,  thirteen,  fifteen,  and  nineteen 
days,  respectively,  after  the  last  dose  of  thymol.  Three  of  these  cases 
were  over  65  years  of  age. 

While  my  experience  with  thymol  in  man  is  very  limited,  I  must 
confess  that  from  my  experiments  upon  animals,  I  am  afraid  of  the 
use  of  alcoholics  per  os  during  treatment,  and  in  the  case  of  weak 
patients  I  should  be  more  inclined  to  use  a  stimulant  hypodermically 
than  run  the  risk  of  dissolving  the  thymol  too  rapidly  or  in  too  great 
quantity  at  one  time.  Furthermore,  it  is  at  least  doubtful  whether 
our  American  hookworm  will  be  so  difficult  to  expel  as  is  the  Old 
World  species,  because  of  the  absence  of  the  ventral  hooks  (cf.  figs.  5 
and  10)  in  Uncinaria  amevicana. 

In  the  case  of  "excessive  debility"  and  other  conditions  which 
Sandwith  designates  as  contra-indications  for  thymol,  it  is  not  clear 
what  drug  Sandwith  would  use,  for  he  states  (1894,  p.  20)  that  "for 


89 

the  last  three  years  I  have  looked  upon  it  as  a  waste  of  time  to  admin- 
ister any  other  anthelminthic  than  thymol  for  this  parasite "  [Agchylo- 
stoma  duodenale\.  Certainly  persons  in  the  conditions  described  should 
not  be  allowed  to  go  untreated,  and  despite  the  view  advanced  by  some 
authors,  smaller  doses  of  thymol,  repeated  one  day  per  week  and 
extending  over  several  weeks,  may  be  expected  to  yield  some  results. 

Male  fern. — Several  European  authors  advise  the  use  of  large  doses 
of  extract  of  male  fern  in  treating  hookworm  disease.  Eichhorst's 
(1901,  p.  314)  recent  "Practice"  places  the  dose  at  10  grams  (2.5  fluid 
drams)  to  20  grams  (5  fluid  drams).  It  has  been  pointed  out  by  Lepine 
(1891a,  1891b)  and  others  that  such  large  doses  of  this  drug  are  likely 
to  be  followed  by  serious  toxic  symptoms  and  even  by  death.  Lepine 
summarizes  the  conditions  as  (1)  symptoms  of  gastrointestinal  irrita- 
tion characterized  by  the  redness  and  the  hemorrhages;  (2)  nervous 
symptoms  (convulsions  and  paralysis);  (3)  albuininuria,  and  (4)  glyco- 
suria,  and  he  warns  not  to  give  over  8  grams  of  the  extract  as  a  maxi- 
mum dose.  Hare  gives  the  dosage  of  the  extract  as  4  to  8  grams 
(about  1  to  2  fluid  drams).  Male  fern  should  be  followed  in  three  to 
four  hours  by  a  calomel  purge,  aided  by  a  saline,  but  not  by  castor  or 
other  oils,  as  the  latter  increase  the  danger  of  absorption,  hence  of 
poisoning. 

Calomel. — While  thymol  is  at  present  considered  the  most  reliable 
remedy  in  hookworm  disease,  indications  are  not  lacking  (see  p.  76) 
that  considerable  good  may  be  accomplished  in  the  American  form  of 
the  disease  by  the  use  of  calomel.  This  drug  will  not,  however,  be 
followed  by  such  prompt  and  satisfactory  results  as  will  thymol. 

GENERAL   TREATMENT. 

The  administration  of  thymol  has  for  its  object  the  expulsion  of  the 
parasite,  hence  the  removal  of  the  cause  of  the  disease.  This  should 
be  supplemented  by  efforts  to  build  up  the  depleted  system  by  means 
of  good  nourishing  food,  iron,  etc.  It  is  well  to  give  the  iron  daily, 
except  on  the  days  that  thymol  is  taken.  Sandwith  (1894,  p.  25) 
claims  that  the  blood  was  most  benefited  by  a  daily  supply  of  1.5  grams 
(23  grains)  of  the  sulphate  of  iron  in  water  in  three  equal  doses. 

PROGNOSIS. 

Among  physicians  I  found  the  view  rather  prevalent  that  the  prog- 
nosis was  poor  for  children  who  presented  severe  cases  of  the  disease. 
This  view  is  probably  due  to  the  fact  that  the  cause  of  the  trouble 
was  not  understood,  hence  treatment  was  not  directed  to  removing 
the  cause. 

The  proposition  now  before  us  is,  first,  to  remove  the  intestinal  par- 
asites, and  second,  to  build  up  the  patients. 


90 

To  accomplish  the  first  desideratum  may  require  some  patience,  but 
efforts  will  eventually  be  successful.  The  second  point  may  also  be 
carried  out,  unless,  of  course,  the  patient  is  too  far  gone  at  the  time 
of  treatment  to  recover  from  the  effects  of  the  disease. 

In  not  all  cases  can  it  be  expected  that  a  dwarfed,  emaciated,  and 
stupid  child  can  be  immediately  placed  upon  the  same  physical  and 
mental  basis  as  his  brothers,  but  even  such  cases  can  be  greatly 
improved. 

LETHALITY    OF    HOOKWORM    DISEASE. 

I  know  of  no  extensive  and  exact  statistics  regarding  the  lethality  of 
uncinariasis,  and  traveling  as  rapidly  as  I  did,  it  was  impossible  to 
establish  any  definite  facts  from  personal  observation,  since  it  was  the 
exception  that  1  saw  any  case  more  than  once.  Furthermore,  owing 
to  the  fact  that  many  light  cases  will  escape  attention,  any  lethality 
percentages  published  will  probably  be  above  the  actual  figures. 

I  doubt  whether  sufficient  data  are  at  hand  to  justify  even  approxi- 
mate statements  regarding  the  lethality  of  hookworm  disease.  That 
numerous  cases,  not  properly  treated,  terminate  fatally  can  not  be 
doubted.  Still,  it  is  remarkable  how  low  a  person  may  be  with  hook- 
worm disease  and  still  live. 

Among  physicians  I  met  with  the  most  contradictory  ideas  on  this 
subject.  Several  excellent  observers  maintained  that  all  severe  cases 
which  reached  an  edematous  condition  were  invariably  fatal;  equally 
keen  observers  doubted  whether  this  disease  was  frequently  the  actual 
cause  of  death;  the  view  was  quite  general  that  patients  suffering  from 
medium  or  severe  attacks  of  this  malady  very  seldom  lived  through 
even  medium  or  light  attacks  of  such  diseases  as  typhoid  fever,  or 
pneumonia,  and  that  severe  attacks  of  malaria  were  frequently  fatal; 
also  that  they  were  very  uncertain  patients  in  confinement. 

In  my  own  observations,  several  points  seemed  quite  significant. 
In  the  first  place,  the  large  number  of  cases  of  long  standing  found  in 
so  many  families  did  not  indicate  a  high  lethality.  Further,  several 
adults  were  seen  who  had  formerly  unquestionably  presented  severe 
infections,  but  who  are  now  in  a  fairly  good  state  of  health.  In  one 
family  with  9  children  living,  most  of  whom  clearly  presented  light, 
medium,  or  severe  infections,  there  was  a  history  of  death  of  9  other 
children,  but  satisfactory  answers  as  to  the  cause  of  these  deaths  were 
not  obtained.  That  some  of  the  children  had  died  of  uncinariasis  is 
very  probable.  On  the  other  hand,  families  were  seen  with  8  to  10 
children,  all  or  nearly  all  in  an  anemic  condition,  some  with  clear 
medium  to  severe  cases  of  uncinariasis,  yet  without  history  of  any 
fatal  case  in  the  family.  I  have  heard  of  localities  in  Central  America 
(but  have  not  investigated  them  personally)  where  it  is  said  that  a  dis- 


91 

ease,  which  from  its  description  I  believe  to  be  uncinariasis,  probably 
due  to  Undnaria  americana,  causes  an  immense  mortality  among  the 
children. 

Taken  all  in  all,  the  data  obtained  did  not  convince  me  that  uncina- 
riasis, per  se,  is  so  fatal  a  disease  in  man  as  is  generally  supposed. 
On  the  other  hand,  I  obtained  the  impression  that  while  very  severe 
cases  are  not  infrequently  fatal,  the  general  effects  of  the  malady 
upon  the  system  are  of  greater  and  more  far-reaching  importance  than 
the  lethality  of  the  infection  itself.  In  other  words,  if  uncinariasis 
were  eliminated,  the  lethal^  of  other  diseases,  such  as  pneumonia, 
typhoid  fever,  malaria,  and  also  of  child  birth,  would  be  decreased, 
and  in  the  sand  and  mixed  sand  and  clay  areas  this  decrease  would  not 
be  an  insignificant  factor. 

One  physician  stated  to  me  that  he  was  confident  that  he  had  lost 
several  hundred  patients  from  uncinariasis  within  the  past  forty 
years. 

Sandwith  (1894,  pp.  16-17)  states  that  of  the  patients  nominally 
under  his  care,  89.5  per  cent  were  cured  or  greatly  improved,  2.5  per 
cent  were  unrelieved,  and  8  per  cent  died. 

"Most  of  the  fatal  cases  had  loud  anemic  murmurs,  marked  subnormal  tempera- 
ture, slight  general  edema,  albuminuria,  and  great  mental  weakness. 

"The  actual  cause  of  death  was  exhaustion,  from  utter  absence  of  rallying  power. 
It  is  difficult  to  believe  that  the  pathological  effects  are  induced  only  by  hemorrhage 
from  the  daily  suction  of  scores  or  even  hundreds  of  worms.  .In  addition  to  the 
loss  of  blood,  we  have  general  thickening  and  degeneration  of  the  duodenum  and 
jejunum,  and  consequent  interference  with  normal  digestion;  then  nonassimilation, 
and  eventually  a  process  of  slow  starvation.  It  is  also  worthy  of  consideration  that 
there  may  be  in  prolonged  cases  some  self-poisoning  from  the  great  number  of  bites 
in  the  walls  of  the  intestines  containing  ill-digested  and  perhaps  decomposing  food." 

POST-MORTEM   APPEARANCES. 

1  did  not  have  occasion  to  make  any  autopsies  during  the  trip; 
hence  I  am  unable  to  present  any  original  observations  in  this  line. 
For  careful  accounts  of  single  cases  of  autopsies,  the  reader  is  referred 
in  American  literature  to  Strong  (1901),  Yates  (1901),  Claytor  (1902a), 
and  Capps  (1903a). 

Sandwith's  (1894,  pp.  17-20)  summary  of  26  autopsies  is  not  acces- 
sible to  many  American  physicians;  hence  it  is  quoted  here  in  full. 

"Some  of  the  earlier  autopsies  were  made  by  myself,  the  later  ones  by  Dr.  Kauf- 
mann.  The  muscles  wrere  in  one  case  described  as  of  normal  color,  but  in  all  others 
they  were  very  pale.  There  was  usually  a  great  absence  of  subcutaneous  fat.  The 
lungs  were  very  pale  and  edematous  in  all  cases,  and  all  the  organs  were  extremely 
bloodless. 

"In  one  case  there  was  noted  edema  of  glottis.  The  heart  was  found  to  be  hyper- 
trophied  ten  times  [in  10  cases],  and  was  very  small  twice!  generally  pale  brown 
in  color,  and  on  three  occasions  there  were  marked  changes  in  the  mitral  valve. 
The  most  common  abnormality  in  the  liver  was  a  brownish-yeliow  fatty  appearance. 


92 

In  one  case  there  were  several  abscesses  and  the  liver  weighed  3,700  grams,  and  in 
one  patient  there  was  well-marked  jaundice. 

"The  spleen  was  enlarged  in  one-third  of  the  post-mortems.  The  kidneys  invari- 
ably showed  some  change,  though  this  was  often  much  more  marked  in  one  kidney 
than  in  the  other.  They  were  very  pale  in  24  patients,  3  of  whom  had  several 
small  cysts.  Of  the  remaining  2  patients  one  had  granular  kidneys  and  the  other 
had  cysts,  but  the  kidneys  were  of  normal  color. 

"The  brain  was  always  exceptionally  white,  and  in  one  case  there  was  recent 
apoplexy. 

"The  small  intestines  showed,  of  course,  the  most  important  changes.  As  a  rule, 
there  were  many  hemorrhages  and  bites  in  the  jejunum  and  ileum,  but  in  one  of  the 
cases  where  the  bites  were  carefully  counted  there  were  only  6  in  the  jejunum  and 
ileum,  and  no  worms  were  found.  In  another  case,  however,  there  were  575  bites 
in  the  small  intestine,  besides  250  anchylostoma.  In  yet  another  there  were  100 
bites,  the  farthest  of  which  was  4.5  meters  from  the  pylorus.  In  only  two  cases 
was  there  much  liquid  blood  in  the  intestine. 

"I  have  not  observed  the  constant  changes  in  the  mucous  membrane  of  the  stomach 
described  by  Giles.  The  great  variability  in  the  number  of  anchylostoma  found  at 
the  autopsies  is  interesting.  In  7  cases,  all  treated  by  thymol  during  life,  no  worms 
could  be  found.  In  an  eighth  case,  also  treated  by  thymol,  but  insufficiently,  there 
were  10  worms.  The  remaining  18  cases  had  not  had  the  advantage  of  thymol.  Six 
of  them,  nevertheless,  were  found  to  have  less  than  10  worms,  and  in  two  of  these 
corpses  only  1  worm  was  found  in  each  jejunum.  Three  other  cases  numbered  20, 
40,  and  50  worms,  but  the  remaining  9  had  numbers  varying  from  170  to  381,  termi- 
nating with  the  maximum  record  of  863.  On  that  occasion  the  autopsy  was  made 
seven  hours  after  death,  and  the  worms  were  scattered  from  a  point  1  inch  beyond 
the  pylorus  for  the  length  of  3  meters;  217  of  the  863  were  attached  still  to  the  intes- 
tine and  were  surrounded  by  much  bloody  mucus,  while  646  were  lying  free  in  the 
intestine;  16  of  the  latter  were  still  alive,  and  one  couple  were  in  copulation. 

' '  Next  the  position  of  the  worms  deserves  notice.  It  was  quite  the  exception  to  find 
any  parasites  in  the  duodenum.  Can  it  be  that  when  the  duodenum  becomes  thick- 
ened and  riddled,  as  it  were,  with  the  ravages  of  former  generations,  the  anchy- 
lostomum  fastens  by  preference  on  to  the  jejunum?  Some  such  cause  as  this 
suggestion  of  gradually  shifting  the  pasture  is  required  to  explain  the  interesting  fact 
that  it  is  not  the  most  advanced  cases  of  anemia  which  will  always  yield  the  largest 
quantity  of  worms.  In  such  cases  the  parasite  must  not  only  have  to  burrow  extra 
deep,  but  the  blood  when  reached  is,  of  course,  deficient  in  quantity.  Or  is  it  that 
the  half-starved  worms  are  dislodged  by  repeated  attacks  of  diarrhea?  The  furthest 
feeding  ground  that  I  have  seen  was  6.30  meters  from  the  pylorus,  where  there  was 
a  worm  firmly  attached. «  But,  as  a  rule,  the  attached  worms  are  all  within  2  meters 
of  the  pylorus,  and  have  their  heads  and  sometimes  half  their  bodies  buried  in  the 
mucous  membrane.  It  is  often  impossible  to  dislodge  them  by  a  strong  stream  of 
water,  and  they  must  then  be  pulled  out  by  forceps. 

' '  I  examined  about  50  cases  to  see  the  proportion  of  male  to  female  worms,  and 
found  it  56  to  44  per  cent.  This  is  not  in  accordance  with  some  of  the  authorities, 
who  say  that  males  are  always  more  rare  than  females,  and  that  males  are  less 
influenced  than  females  by  the  action  of  expellent  drugs." 


a  "Dubini  has  only  once  seen  the  worm  in  the  ileum.  The  nearest  feeding  ground 
seen  by  me  was  24  centimeters  from  the  pylorus.  In  that  case  there  were  100  worms 
attached  and  281  detached,  besides  oxyurides." 


93 

PREVENTION    OF    HOOKWORM    DISEASE. 

Iii  llir  prevention  of  diseases  caused  by  animal  parasites,  we  may,  of 
course,  attempt  to  attack  the  infectious  agent  in  any  stage  of  its  life 
history.  In  connection  with  uncinariasis,  three  periods  in  particular 
come  into  consideration,  namely:  (1)  The  adult  worm  in  the  intestine; 
(-2)  the  egg  in  the  feces,  and  (3)  the  infecting  ("encysted")  stage  of 
the  larva. 

(1)    ADULT   WORM    IN   THE    INTESTINE;    TREATMENT. 

The  destruction  of  the  adult  worm  in  the  intestine  not  only  relieves 
the  patient  of  an  important  and  (when  present  in  large  numbers) 
serious  or  even  dangerous  parasite,  but  it  is  also  an  important  factor 
in  preventing  the  spread  of  the  disease  to  other  people.  Accordingly, 
treatment  should  be  instituted  even  if  the  eggs  found  in  the  feces  are 
so  few  in  number  as  to  indicate  only  a  light  infection. 

Not  infrequently  the  opinion  is  expressed  that  the  infection  with 
parasites  found  in  a  given  patient  is  so  light  that  treatment  is  hardly 
necessary.  Such  a  view,  however,  is  often  very  shortsighted,  for  it  is 
not  infrequently  light  infections  occurring  at  unfavorable  seasons  and 
under  unfavorable  conditions  that  furnish  the  material  for  heavy 
infections  at  more  favorable  times.  No  Uncinaria  infection  in  man 
is  too  light  to  be  worthy  of  treatment,  for  each  adult  female  may  lay 
eggs;  hence  the  destruction  of  these  females  means  the  decrease  of 
scores  of  free  infectious  larvae. 

Not  all  cases  of  the  malady  can  be  recognized  without  the  micro- 
scope; hence  many  people  will  unconsciously  spread  the  disease- 
producing  agent.  Furthermore,  many  cases  which  might  be  recog- 
nized by  symptoms  will  not  come  under  medical  treatment,  so  that 
they,  too,  will  spread  the  infectious  material.  It  is  clear,  therefore, 
that  for  satisfactory  results  in  prevention  we  must  adopt  some  method 
in  addition  to  the  treatment. 

(2)     EGGS    IN   THE    FECES  |    CONTROL    AND   DESTRUCTION. 

It  is  in  the  feces  that  we  find  the  potentially  infectious  material  in 
the  most  concentrated  form.  After  the  eggs  develop  into  embiyos 
the  latter  may  leave  the  fecal  matter  and  be  distributed  in  the  sand  or 
in  the  water.  Accordingly,  it  is  much  easier  to  control  or  destroy 'a 
given  amount  of  infectious  matter  while  it  is  concentrated  in  the 
feces  than  it  is  later  when  it  is  spread  over  a  larger  area.  Here,  in 
fact,  we  have  the  key  .to  the  prevention  of  uncinariasis.  Proper  dis- 
posal of  the  fecal  discharges  will  make  the  spread  of  uncinariasis 
impossible.  As  such  proper  disposal  I  will  suggest:  Properly  built 
privies  when  sewerage  is  lacking;  use  of  such  outhouses  after  con- 
struction; cleaning  the  same  at  regular  intervals,  and  burial,  burning, 
disinfection,  or  drying  of  the  feces. 


(3)   THE  INFECTING  ( ' *  ENCYSTED ")  STAGE  OF  THE   LARVA. 

Disinfection  of  premises. — A  chemical  disinfection  of  premises  to 
kill  the  free  stages  of  eggs,  embryos,  and  larvae  of  the  parasite  would 


hardly  be  practicable,  but  heat,  dryness,  and  cold  all  result  in  killing 
these  organisms. 


95 

About  twenty-four  to  forty-eight  hours  of  freezing  temperature 
kills  the  free  infection,  hence  after  any  cold  weather  of  this  kind  in 
winter  it  may  be  assumed  that  the  premises  are  disinfected. 

After  any  especially  dry  weather,  most  if  not  all  the  free  infection 
(except  such  as  exists  in  places  not  affected  by  the  dryness)  is  killed, 
so  that  exposed  portions  of  premises  may  be  assumed  to  be  practically 
disinfected. 

Spraying-  with  burning  oil  (fig.  86),  as  practiced  by  the  Massachusetts 
Gypsy  Moth  Commission,  will  effectually  disinfect  any  area.  If  a 
spray  nozzle  or  "cyclone  burner"  is  not  at  hand,  the  ground  around 
the  house  could  be  strewn  with  straw  or  brush  and  set  afire  (due  pre- 
caution being  taken  not  to  burn  the  house),  thus  thoroughly  disinfecting 
the  premises.  (See  Stiles,  1902  d.) 

Drinking  water. — To  tell  the  average  farm  hand  or  miner  that  he 
should  always  "boil  or  filter"  the  water  before  drinking  it  is,  academ- 
ically, a  step  toward  preventing  infection  with  uncinariasis.  Practi- 
cally, however,  it  is  a  step  toward  throwing  away  whatever  influence 
we  may  happen  to  have  with  him.  Theoretical^,  we  should  teach  this 
simple  hygienic  precaution  to  all  families,  both  in  the  city  and  in  the 
country.  Practically,  we  are  in  many  cases  weakening  our  position 
by  insisting  too  generally  upon  this  point. 

While,  therefore,  we  may  warn  people  to  boil  or  filter  their 
drinking  water  in  order  to  prevent  the  introduction  of  the  infecting 
agent  of  uncinariasis  or  of  other  diseases,  provided  we  see  any  chance 
of  their  following  the  advice  (in  regard  to  which  we  ourselves,  except 
in  times  of  epidemics,  are  very  inconsistent),  we  will,  I  believe, 
usually  weaken  our  influence  with  the  poorer  classes  in  mentioning 
a  precaution  which  the  average  farm  hand  naturally  looks  on  as 
absurd.  It  is  much  more  important  to  urge  him  to  locate  his  privy 
some  distance  from  the  well.  That  is  a  proposition  he  can  appreciate; 
the  necessity  for  boiling  or  filtering  drinking  water  is  usually  beyond 
his  mental  horizon. 

Clean  hands. — An  important  point  in  connection  with  preventing 
the  ingestion  of  the  infectious  agent  of  uncinariasis  is  that  the  hands 
and  finger  nails  should  be  kept  clean.  I  am  inclined,  however,  to  take 
an  ultrapractical  view  of  cleanliness  versus  dirt  in  connection  with 
country  houses,  and  to  first  see  that  the  inevitable  dirt  shall  be  clean 
This  can  be  accomplished  if  we  can  succeed  in  having  properly  con- 
structed latrines,  built  at  proper  distance  from  the  wells  and  houses, 
if  the  children  be  taught  to  use  them,  and  if  the  parents  be  taught  the 
necessity  for  cleaning  them. 

These,  in  my  opinion,  are  the  first  steps  to  be  taken,  and  far  out- 
weigh all  such  considerations  as  boiling  and  filtering  drinking  water 
or  keeping  the  hands  clean. 

Wearing  shoes. — Wearing  shoes  during  wet  weather  and  washing  the 
feet  frequently  will  prevent  the  cutaneous  infection  and  will  protect  to 


96 

a  great  extent  against  ground  itch.  It  can  hardly  be  expected,  how- 
ever, that  the  poorer  children  in  country  districts  will  adopt  this 
precaution  to  any  extent. 

COMMON  INTERPRETATION  OF  HOOKWORM  DISEASE. 

Upon  several  former  occasions  I  have  referred  to  "cases  of  anemia 
of  obscure  origin"  as  possibly  due  to  uncinariasis.  In  a  recent  paper 
(Stiles,  1902b,  pp.  207-208)  I  referred  to  ' ;  dirt-eating  "  as  being  possibly 
connected  with  uncinariasis;  it  was  also  intimated  (1902b,  p.  215),  upon 
authority  of  Dr.  Kirby-Smith,  that  in  Mississippi  uncinariasis  is  con- 
fused with  malaria;  Harris  (1902c)  also  points  out  that  much  of  the 
anemia  attributed  to  malaria  and  dirt-eating  is  probably  due  to  hook- 
worm disease. 

At  present  I  am  able  to  make  more  specific  statements  than  for- 
merly. The  condition  which  should  be  attributed  to  light  infections 
of  uncinariasis  is  usually  interpreted  as  due  to  malaria  or  diarrhea; 
medium  cases  are  usually  interpreted  as  an  anemia  due  to  malaria 
combined  with  "improper  diet"  or  "insufficient  nourishment;"  severe 
cases  are  usually  attributed  to  "malarial  cachexia,"  "dirt-eating," 
"resin-chewing,"  "heart  disease,"  "dropsy,"  "general  debility," 
"pernicious  anemia,"  and  "lack  of  proper  nourishment."  Such  at 
least  are  the  most  common  diagnoses  which  have  been  made  by  the 
attending  physicians  in  the  cases  which  I  have  interpreted  as  light, 
medium,  or  severe  infections  with  Uncinaria  americana. 

ECONOMIC  IMPORTANCE  OF  HOOKWORM  DISEASE. 

Malaria  is  admittedly  one  of  the  most  important  diseases  when 
viewed  from  an  economic  standpoint.  In  general,  uncinariasis  is,  in 
the  South,  fully  as  important  as  malaria,  and  in  some  respects  it  is  of 
even  greater  importance. 

Take  a  given  farming  area  in  the  sand  district  with  an  infection  of 
uncinariasis,  and  assume  that  100  farm  hands  are  employed.  It  is  not 
an  exaggeration  to  say  that  these  100  people  are  not  doing  the  work 
of  80  or  90  average  hands.  Thus  there  is  a  distinct  loss  of  10  to  20 
per  cent  in  the  wages  and  a  corresponding  loss  in  the  crop  returns. 
In  some  places  I  should  estimate  the  loss  at  even  a  higher  percentage, 
say  an  average  of  25  per  cent,  while  in  several  families  which  I  have 
examined  I  should  say  that  uncinariasis  is  reducing  the  laboring 
capacity,  hence  the  productiveness,  of  the  family  to  as  low  as  30  to  40 
per  cent,  thus  entailing  a  loss  of  60  to  70  per  cent. 

Nor  are  the  losses  in  wages  and  in  the  laboring  capacity,  and  the 
decrease  of  productiveness  of  the  family,  hence  of  the  farm,  and  finally 
of  the  county  and  State,  the  only  economic  considerations  involved. 
Cases  are  not  unknown  where  families  have  sold,  moved,  or  destroyed 
their  homes,  or  were  about  to  do  so,  because  of  the  existence  of  this 
disease  and  because  of  the  belief  that  it  might  be  due  to  the  locality 
in  which  they  lived. 


97 


Again,  it  is  almost  a  common  experience  to  be  told  by  the  father 
of  a  family  that  he  spends  for  medicine  all  he  earns,  in  the  hope  of 
ridding  his  children  of  this  malady.  Add  to  this  the  physicians'  bills, 
the  loss  by  death  and  funeral  expenses,  etc.,  and  it  is  seen  that  this 
infection  is  keeping  more  than  one  family  in  absolute  poverty. 

Nor  should  we  forget  that  unciriariasis  has  its  important  bearing 
upon  the  mental  as  well  as  upon  the  physical  and  financial  development 
of  the  poorer  white  people.  As  already  stated,  children  infected  with 
this  malady  are  often  underdeveloped  mentally;  frequently  they  have 
a  reputation  in  the  schools,  in  the  neighborhood,  and  in  their  own 
family,  of  being  " stupid,"  or  "dull,"  or  " backward"  in  their  studies, 
etc.  It  has  already  been  mentioned  that  children  suffering  w.ith  this 
disease  are  frequently  kept  home  from  school  because  of  their  tendency 
to  become  edematous  when  they  sit  still  for  any  length  of  time. 
When  we  now  recall  that  these  conditions  coincide  especially  with  the 
educational  period,  it  should  not  seem  strange  that  uncinariasis  has  a 
marked  influence  upon  the  general  intellectual  condition  of  the  dis- 
tricts in  which  it  occurs. 

Considering  the  subject  in  the  light  of  all  I  saw  on  the  trip,  and 
taking  what  I  believe  to  be  a  conservative  view  of  the  subject,  I  find 
it  exceedingly  difficult  to  escape  the  conclusion  that  in  uncinariasis, 
caused  by  Uncinaria  americana,  we  have  a  pathologic  basis  as  one  of 
the  most  important  factors  in  the  inferior  mental,  physical,  and  financial 
condition  of  the  poorer  classes  of  the  white  population  of  the  rural 
sand  and  piney  wood  districts  which  I  visited.  This  sounds  like  an 
extreme  statement,  but  it  is  based  upon  extreme  facts. 

By  this  position  I  do  not  intend  to  assert  that  uncinariasis  is  the 
only  factor  which  comes  into  consideration.  The  warm  climate  and 
the  monotonous  diet,  and  probably  also  the  excessive  use  of  tobacco 
in  some  cases,  are  not  without  influence.  Still,  with  uncinariasis  as  it 
exists  to-day,  these  people  are  suffering  from  a  handicap  in  life  which 
practically  removes  them  from  a  fair  chance  in  competition.  If  the 
uncinariasis  is  removed  they  will  be  placed  in  a  more  favorable  con- 
dition both  subjectively  and  objectively.  With  the  present  prevalence 
of  uncinariasis  their  lack  of  ambition  is  perfectly  natural;  remove  the 
disease  and  they  can  develop  ambition. 

On  the  other  hand,  if  we  were  to  select  the  strongest  people  in  the 
country  and  place  them  in  the  conditions  under  which  these  patients 
are  now  living  it  would  be  only  a  generation  or  two  before  even  a 
race  of  athletes  would  be  in  the  same  condition  as  the  persons  under 
discussion. 

The  conditions  described  are  familiar  to  persons  who  have  visited 
the  rural  sand  districts.  But  they  have  existed  for  so  many  years  that 
many  of  us  to-day  look  upon  them  as  natural,  hence  they  do  not 
attract  the  consideration  to  which  they  are  entitled. 

19558— No.  10—03 7 


98 


GEOGRAPHIC  DISTRIBUTION  AND  ABSTRACTS  OF  CASES  FOUND  IN 
THE  UNITED  STATES. 

In  a  former  paper  (Stiles,  1902b,  pp.  206-217)  I  gave  abstracts  of 
all  the  cases  of  uncinariasis  known  to  me  at  that  time  for  the  United 
States.  The  disease  is  now  proved  to  be  so  common  in  certain  por- 
tions of  the  country  that  it  is  hardly  necessary  to  keep  a  full  record  of 
every  case  found,  but  on  account  of  the  medico-historical  interest  asso- 
ciated with  the  subject,  and  also  in  order  to  complete  the  literature  and 
details  of  geographic  distribution,  there  are  here  added  abstracts  and 
notices  of  various  cases  which  have  come  to  my  knowledge  since  the 
above-mentioned  paper  was  completed. 

NEW  ENGLAND  STATES. 
NEW  HAMPSHIRE. 

No  positively  diagnosed  cases  of  hookworm  disease  seem  to  be 
recorded  for  this  State. 

Center  Eppingham,  1876  -  ?  1  case,  ?  death. 

GOULD  (1876,  pp.  417, 418)  refers  to  a  case  of  pica  or  dirt-eating  which  sounds  sus- 
piciously like  uncinariasis. 

MIDDLE  STATES. 

NEW  YORK. 

Rochester,  1868  .  .  -  ?  1  case,  ?  death. 

ELY  (1868,  pp.  101, 102)  describes  a  case  of  chalk-eating  which  may  possibly  have 
been  due  to  uncinariasis,  though  this  is  by  no  means  certain. 

Buffalo,  1896  _  _  . .5  cases,  0  death. 

MCEHLAU'S  (1897)  cases.  See  STILES  (1902b,  p.  209).  Doubts  have  arisen  in  the 
minds  of  some  physicians  as  to  whether  these  were  actually  cases  of  uncinariasis. 

Glen  Island,  1900  _ .  A  cases,  0  death. 

ASHFORD'S  cases  from  Porto  Rico.  Probably  due  to  Uncinaria  americana;  reported 
in  STILES  (1902b,  p.  210). 

Stapleton_  __1  case,  0  death. 

BAILHACHE'S,  and  GREENE'S  (1901)  case.  Place  of  infection  uncertain.  See  STILES 
(1902b,  p.  215). 

Albany,  1900. .-1  case,  0  death. 

WARD  (1902,  pp.  23-26):  American,  physician,  32  years  old.  Had  served  inU.  S. 
Army  in  the  Philippines.  Albany  hospital,  Feb.  6,  1902.  Report  on  feces  by  Dr. 
GEORGE  BLUMER,  confirmed  by  Dr.  W.  S.  THAYER. 

?  Albany,  1900. .  .  .1  case,  0  death. 

NEUMAN  and  BLUMER.     Details  of  case  not  known  to  me. 


99 

PENNSYLVANIA. 

It  is  by  no  means  impossible  that  uncinariasis  will  be  found  among 
the  miners  of  Pennsylvania.  As  so  many  of  these  men  are  immigrants 
from  Europe,  the  Old  World  species,  Agchylostoma  duodenale  may  be 
expected. 

Philadelphia,  1900-1901  _ .    3  cases,  0  death. 

BOSTON'S  cases  reported  by  ALLYN  and  BEHREND  (1901).  See  STILES  (19Q2b,  p.  211). 
Probably  due  to  Uncinaria  americana. 

Philadelphia,  1901  _.    - 1  case,  0  death. 

ALLYN  and  BEHREND' s  (1902)  case,  imported  from  Italy,  hence  due  to  Agchylostoma 
duodenale. 

MARYLAND. 

Baltimore,  1900 . 2  cases,  0  death. 

HEMMETER'S  (1902)  cases;  probably  infected  in  Porto  Rico  and  due  to  Uncinaria 
americana.  See  STILES  (1902b,  p.  210). 

Baltimore,  1901 1  case,  1  death. 

HALL'S  (1901)  case;  imported,  possibly  from  Vera  Cruz.  Due  to  Agchylostoma 
duodenale.  See  STILES  (1902b,  pp.  213-215). 

Baltimore,  1902  _ . , 1  case,  0  death. 

OSLER'S  case  [unpublished].  In  Johns  Hopkins  Hospital.  Patient  came  from 
North  Carolina.  Parasites  determined  by  Boggs  as  Uncinaria  americana,  confirmed 
by  Stiles. 

DISTRICT   OF   COLUMBIA. 

Washington,  1901 __-[!  case,  1  death.] 

CLAYTOR'S  (1901a,  1902a)  case,  from  Westmoreland  County,  Va.,  due  to  Uncinaria 
americana.  See  STILES  (1902b,  pp.  211-212) . 

Washington,  1902 1  case,  0  death. 

HERRICK  (1902,  p.  101):  Male,  37  years  old,  lived  in  Germany  until  1897.  Sent  to 
Philippine  Islands  September,  1899.  "  Present  illness  began  in  July,  1900,  with  an 
attack  of  diarrhea.  He  had  from  10  to  15  movements  daily  for  three  months,  with  a 
moderate  amount  of  tenesmus.  Mucus  and  blood  appeared  in  the  stools  after  the 
first  month,  giving  them  a  dark  tarry  appearance.  He  lost  weight  and  strength 
rapidly  during  this  time  and  gradually  became  short  of  breath  on  slightest  exertion. 
This  was  followed  by  a  period  of  improvement,  the  stools  becoming  less  frequent;  but 
in  January,  1901,  he  became  worse  and  was  sent  to  the  hospital  at  Iloilo.  Since  then 
he  has  been  confined  to  hospitals,  on  account  of  weakness  and  dyspnea.  In  Septem- 
ber, 1901,  the  diarrhea  ceased,  and  although  he  has  gained  a  little  weight  he  has  been 
steadily  growing  weaker.  At  no  time  had  he  been  subject  to  hemorrhages  other 
than  stated. 

"Physical  examination  shows  an  apparently  well-nourished  man  with  a  peculiar 
lemon-yellow  pallor;  conjunctivas  and  mucous  membranes  are  pale;  slight  oedema  of 
the  ankles  is  present.  He  has  marked  dyspnoea  on  the  slightest  exertion.  The  lungs 
are  negative;  the  heart  is  enlarged;  the  point  of  maximum  impulse  is  in  the  fifth 
intercostal  space  in  the  nipple  line.  A  soft  blowing  systolic  murmur  is  audible  at 
the  apex  and  in  the  pulmonic  area.  Liver  dullness  extends  from  the  sixth  intercostal 
space  in  the  nipple  line  to  1  cm.  below  the  costal  margin.  The  edge  is  palpable.  The 
spleen  is  enlarged  and  the  edge  is  palpable  at  the  costal  margin.  The  urine  is  negative. 


100 

"The  blood  is  very  pale  and  watery;  a  moderate  poikilocytosis  is  present;  there 
are  no  nucleated  red  corpuscles  and  no  malaria  organisms  present.  The  blood  count 
shows:  Bed  corpuscles,  1,120,000;  hemoglobin,  18  per  cent;  leucocytes,  about  4,000; 
polymorphonuclear,  52  per  cent;  eosinophiles,  26.8  per  cent;  small  inononuclear,  14 
per  cent;  large  mononuclear,  4.4  per  cent;  transitional,  2.8  per  cent. 

"One  month  later,  the  patient  meantime  having  been  taking  arsenic  and  iron,  the 
blood  count  was  as  follows:  Ked  corpuscles,  1,450,000;  hemoglobin,  22  per  cent;  leu- 
cocytes, 2,000;  polymorphonuclear,  61  per  cent;  eosinophile,  18.2  per  cent;  small 
mononuclear,  16.4  per  cent;  large  mononuclear,  3.2  per  cent;  transitional,  1.2  per 
cent;  no  nucleated  red  cells. 

"There  had  been  practically  no  change  in  the  patient's  condition.  The  liver  and 
spleen  were  as  in  the  former  note,  and  the  dyspnoea  was  marked.  Numerous  typical 
ovums  of  the  Uncmaria  were  present  in  the  stools,  but  no  adult  forms  were  seen. 
After  the  usual  thymol  treatment  about  60  adult  worms  were  found.  They  resembled 
in  all  respects  Uncmaria  duodenalis,  and  were  identified  by  Dr.  Stiles  as  the  Old 
World  hookworm.  The  ovums  present  were  in  the  progress  of  segmentation,  4  to  12 
cells  being  visible.  None  were  seen  containing  an  embryo,  as  frequently  occurs  in 
the  form  Uncinaria  americana,  described  by  Dr.  Stiles. 

"Blood  examinations,  ten  and  twenty  days  after  the  thymol  treatment  was  begun, 
showed  the  following  counts: 


I 
May  28,  1902.   June  7,  1902. 

Red  corpuscles 

2  300  000            3  100  000 

Hemoglobin  

....        .           .  .  per  cent 

'23                      '27 

Leucocytes.  . 

number 

2  500                    3  000 

Polymorphonuclear  

per  cent. 

54                         62 

Eosinophile  

.do 

21                         14 

Small  inononuclear  . 

do 

17                         17 

Large  mononuclear 

do 

6                           6 

Transitional  

do. 

2                           1 

"The  general  condition  is  also  improving  rapidly,  although  the  parasites  are  not 
entirely  eliminated,  as  an  ovum  is  still  occasionally  found  in  the  stools." 

Anacostia  (Government  Hospital  for  the  Insane),  1902  _  16  cases, 0  death. 
Cases  found  on  microscopic  examination  by  Stiles,  Garrison,  Ransom,  and  Steven- 
son, of  United  States  Public  Health  and  Marine-Hospital  Service.     Probably  most 
if  not  all  of  these  were  infected  in  other  localities.     (See  p.  37.) 

VIRGINIA. 

Essex  County,  ?  date g  cases,  ?  deaths. 

Passed  Asst.  Surgeon  JOHN  F.  ANDERSON  has  stated  to  me  that  there  exists  in  Essex 
County  a  condition  of  '  'bloat' '  and  anemia  which  is  usually  attributed  to  dirt-eating, 
and  which  corresponds  in  general  to  the  conditions  described  in  this  paper. 

Richmond,  1852 . .  .  _  ?  1  case,  0  death. 

POLLARD  (1852,  p.  185)  reports  a  case  of  dirt-eating.  Its  connection  with  uncina- 
riasis  is  possible,  but  not  clear. 

Richmond,  1898 1  or  2  cases,  0  death. 

GRAY'S  (1901)  case.     See  STILES  (1902b,  p.  209). 
Westmoreland  County,  1901 1  case,  1  death. 

CLAYTOR'S  case.     See  District  of  Columbia. 
Westmoreland   County,  ?  date 2  cases,  0  death. 

Referred  to  by  STUART  in  STILES  (1901,  p.  525,  and  1902b,  p.  212). 


101 

NORTH    CAROLINA. 

Judging  from  the  size  of  the  eggs,  all  the  cases  I  found  in  North 
Carolina  were  due  to  T7ncinaria  americana. 

Roanoke  River  Valley,  prior  to  1808 :.\  cases,  ?  deaths. 

PITT  (1808)  states  that  malacia  or  dirt-eating  "prevails  mostly  among  the  poorer 
white  people  and  negroes,  and  originates  in  my  opinion  from  a  deficiency  of  nourish- 
ment." He  refers  also  to  the  slowly  healing  ulcers  on  the  legs,  and  to  the  ''tallow 
complexion."  His  general  description  points  quite  distinctly  to  uncinariasis. 

Person  County,  1832 ?  cases,  ?  deaths. 

JORDAN  (1832,  pp.  18-30)  gives  a  discussion  of  dirt-eating  which  quite  positively 
refers,  at  least  in  part,  to  uncinariasis. 

Durgy,  Person  County,  1902 .  _  2  cases,  0  death. 

STILES  (1903b,  p.  38). 
Cumnock  Coal  Mines,  Chatham  County,  1902 Tease,  0  death. 

STILES  (1903b,  p.  38). 
Gaston  County,  about  1880 ?  cases,  ?  deaths. 

The  following  interesting  letter  has  been  received  from  Dr.  Barringer,  and  indi- 
cates the  presence  of  uncinariasis  in  Gaston  County: 

"DEAR  SIR:  I  have  just  seen  in  the  Marine-Hospital  Service  Public  Health  Reports 
your  letter  of  October  22,  from  Kershaw,  S.  C.  I  was  for  many  years  located  in  the 
district  in  which  you  have  been  working,  and  your  letter  has  thrown  an  immense 
amount  of  retrospective  light  on  what  I  saw  there.  My  wrork  was  done  in  the  early 
eighties,  and  yet  I  still  remember  many  cases  of  pernicious  anemia,  which  was  accom- 
panied in  some  cases  by  dropsical  effusions  and  diarrhea,  a  combination  I  could 
never  make  out,  and  yet  this  must  have  been  uncinariasis. 

"Whole  sections  of  the  illicit  distillers  of  Kings  Mountain,  in  Gaston  County,  N.  C., 
were  affected,  and  the  dirt-eating  whites  of  this  section  seemed  to  have  a  malady  dif- 
ferent from  those  of  the  better  class  in  the  neighborhood.  I  tried  a  tannic  acid 
preparation,  which  seemed  to  do  more  good  than  anything  else,  and  I  wish  now  I 
had  tried  Areca  nut.  By  the  bye,  I  also  recall  that  my  pointer  dogs  in  this  section 
seemed  to  be  afflicted  in  the  same  way.  During  my  stay  in  Gaston  County,  from 
1878  to  1881,  I  lost  two  dogs,  who  used  to  follow  me  around  to  these  houses,  from  an 
unknown  disorder. 


' '  I  remain,  yours,  very  respectfully, 

"P.  B.  BARRINGER,  Chairman. 
"Dr.  CH.  WARDELL  STILES, 

' '  Care  Marine-Hospital  Service,  Washington,  D.  C. " 

SOUTH   CAROLINA. 

Judging  from  the  measurements  of  the  eggs,  all  the  cases  I  found 
in  South  Carolina  were  due  to  Uncinaria  americana. 
Date  ? ?  cases,  ?  deaths. 

HEUSINGEB  and  GEDDIXGS,  quoted  by  BLANCHARD,  1888a,  could  not  be  traced. 
Adams  Run,  Colleton  County,  1902 4  cases,  0  death. 

STILES  (1903b,  p.  41):  Orphans  at  Charleston. 


102 

Barnwell  County,  1902 .  _  .1  ease,  0  death. 

STILES  (1903b,  p.  41):  Medical  student  at  Charleston. 
Berkeley  County,  1902 _  _ .  3  cases,  0  death. 

STILES  (1903b,  p.  41):  Orphans  at  Charleston. 
Camden,  Kershaw  County,  1902  . .  i  _  _2  cases,  0  death. 

STILES  (1903b,  p.  39):  Brickyard.    ' 
Charleston,  Charleston  County,  1902  _  __  __3  cases,  0  death. 

Dr.  DE  SAUSSURE,  quoted  by  STILES  (1903b,  p.  41):  Source  of  infection  not  stated. 

Charleston  County,  1902 _ .  __2  cases,  0  death. 

STILES  (1903b,  p.  41):  Medical  students  at  Charleston;  came  from  seacoast  islands. 
Charleston,  Charleston  County,  1902_  _  __[15  cases,  0  death.] 

STILES  (1903b,  p.  41):  At  orphan  asylum.  Children  came  from  Dorchester  (1), 
Berkeley  (3),  Colleton  (4),  and  Charleston  (7)  counties 

Charleston,  Charleston  County,  1902  _.  _  .[4  cases,  0  death.] 

STILES  (1903b,  p.  41):  Medical  students  from  Barnwell  (1),  Florence  (1),  and 
Charleston  (2)  counties. 

Florence,  Florence  County,  1902 1  case,  0  death. 

STILES  (1903b,  p.  41):  Medical  student  at  Charleston. 
Lancaster  and  Kershaw  counties,  1902 about  50  cases,  0  death. 

STILES  (1903b,  pp.  40-41). 

McClellanville,  Charleston  County,  1902 _ .      4  cases,  0  death. 

STILES  (1903b,  p.  41.) :  Orphans  at  Charleston. 
Plum  Island,  Charleston  County,  1902 3  cases,  0  death. 

STILES  (1903b,  p.  41):  Orphans  at  Charleston. 
Summerville,  Dorchester  County,  1902 1  case,  0  death. 

STILES  (1903b,  p.  41):  Orphan  at  Charleston. 

GEORGIA. 

Judging  from  the  size  of  the  eggs,  all  the  cases  I  found  in  Georgia 
were  due  to  Uncinaria  americana.  Harris  states  that  his  cases  were 
due  to  the  same  species. 

Locality  ?  Date  ? ?  cases,  ?  deaths. 

LYELL  quoted  by  BLANCHARD  (1888a),  could  not  be  traced. 

Richmond  County,  1836 .  _  ?  cases,  ?  deaths. 

COTTING  (1836a,  pp.  288-290)  states  that  clay  is  eaten  by  many  people,  especially 
by  children.  Probably  at  least  some  of  the  cases  were  connected  with  uncinariasis. 

Pine  Barrens  of  Georgia,  1845  . .  ?  cases,  ?  deaths. 

LECONTE  (1845,  pp.  417-444)  states  that  dirt-eating  is  common  in  the  pine  barrens 
of  Georgia.  His  description  refers  quite  clearly  to  uncinariasis,  at  least  in  part. 


103 

Appling  County,  1902  _  _.l  case,  ?  death. 

HARRIS  (1902a,  pp.  99-100) :  Male,  farmer,  29  years  old.  Healthy  until  14  years  of 
age,  then  observed  that  he  was  never  go  well  in  latter  part  of  winter  and  spring  as 
in  summer  and  fall.  Anemic;  weak;  food  tastes  salty;  in  spring  the  arms,  hands, 
and  dorsal  surface  of  feet  become  greatly  inflamed,  blisters  form,  followed  by  scabs; 
severe  constipation;  pains  in  neck  and  stomach;  vomiting  frequent;  weight  117 
pounds;  skin  pale  and  wrinkled,  smooth  and  dry;  very  little  beard;  mucous  mem- 
branes very  pale;  tongue  moist,  shows  indentations  of  teeth,  and  its  epithelium  in  a 
large  measure  absent;  teeth  small,  quite  a  number  of  them  decayed;  pulse  90,  res- 
piration 20,  temperature  98°  F.;  body  somewhat  emaciated;  heart  with  soft,  blowing 
systolic  murmur  constant,  varying  greatly  in  intensity;  marked  venous  hum  over 
right  jugular;  just  below  the  ensiform  cartilage  and  to  the  left  great  tenderness; 
stomach  normal  in  size  and  position;  after  Ewald  trial  meal,  total  acidity  64,  HC1 
40,  combined  HC1  4,  phosphates  4;  spleen  and  intestines  normal;  feces  dark  brick- 
red;  Uncinaria  eggs  present;  urine  2,300  cm.  in  twenty-four  hours,  light  yellowish- 
red;  specific  gravity,  1.012,  faintly  alkaline,  no  sugar,  at  one  time  faint  ring  of 
albumin,  albumose  not  present;  urea  in  twenty-four  hours,  21.15  grams,  uric  acid 
0.475  gram,  chlorids  3.15,  phosphates  2.37,  sulphates  2.82  grams.  Blood:  Red  cor- 
puscles 1,760,000,  white  4,020,  hemoglobin  20  per  cent;  decided  though  not  extreme 
poikilocytosis,  a  number  of 'microcytes;  a  few  nucleated  reds;  small  lymphocytes  28, 
large  lymphocytes  14,  transitional  6,  polymorphonuclear  leucocytes  50,  eosinophiles 
2.  Vision,  right  eye  15-20,  left  eye  15-30.  Diagnosis:  Anchylosfomiasis  and  pos- 
sibly pellagra.  Treatment:  Afternoon,  10  grains  of  calomel;  next  day,  7  a.m.,  30 
grains  of  thymol  in  capsules;  9  a.  m.,  30  grains  of  thymol;  8  p.  m.,  large  dose  of  salts. 
Stools  contained  at  least  420  worms. — HARRIS,  1902b,  pp.  220-227.  Same  case. 

Porter  Springs  _  .  A  cases,  0  death. 

Letter  of  H.  F.  HARRIS,  dated  August  9,  1902,  to  IT.  S.  Bureau  of  Animal  Indus- 
try. He  states:  "  I  am  absolutely  sure  that  this  disease  is  very  common  in  all  this 
region."  One  of  the  four  cases  probably  originated  in  Troup  County,  the  other 
three  in  Lumpkin  or  neighboring  county. 

Locality  ?,  1902  .  __7  cases,  0  death. 

HARRIS  (1902c,  p.  776)  states  that  since  reporting  his  first  case  he  has  discovered 
eleven  new  cases  for  Georgia.  See  also  Porter  Springs. 

Atlanta,  1902  _  _  1  case,  1  death. 

CLAUDE  A.  SMITH  (1902,  p.  1062):  Case  reported;  mentioned  also  a  similar  case  in 
a  dog  which  had  eaten  some  of  the  infected  feces  of  the  patient.  Man  died  of  pleu- 
ritic abscess.  The  specimens  were  collected  post-mortem  in  a  negro  at  Grady  Hos- 
pital, Atlanta. 

Dr.  Smith  kindly  sent  me  the  parasites  for  examination.  The  specimens  from 
man  (B.  A.  I.,  No.  3423)  proved  to  be  Uncinaria  americana,  while  those  from  the 
dog  (B.  A.  I.,  Nos.  3424  and  3425)  were  Agchylostoma  caninum. 

Atlanta,  November,  1902  _  _  _2  cases,  0  death. 

CLAUDE  A.  SMITH  informed  me  in  a  personal  letter  dated  December  3,  1902,  that 
he  had  just  observed  two  cases,  both  from  Florida.  One  was  a  man  50  years  old, 
the  other  a  dental  student. 

Albany,  Dougherty  County,  1902 about  5  cases,  0  death. 

STILES  (1903b,  p.  43):  People  did  not  belong  in  Albany. 

Americus,  Sumter  County,  1902 1  case,  0  death. 

STILES  (1903b,  p.  41) :  Orphan  in  Macon. 


104 

Baxley,  Appling  County,  1902  _ .  . .  ,1  case,  0  death. 

STILES  (1903b,  p.  42):  Orphan  in  Macon. 
Buena  Vista,  Marion  County,  1902 2  cases,  0  death. 

STILES  (1903b,  p.  41):  Orphan  in  Macon. 
Cordele,  Dooly  County,  1902  _  ._!  case,  0  death. 

STILES  (1903b,  p.  42):  Orphan  in  Macon. 
Darien,  Mclntosh  County,  1902.  _  lease,  0  death. 

STILES  (1903b,  p.  42):  Orphan  in  Macon. 
Effingham  County,  1902  _ .  1  case,  0  death. 

STILES  (1903b,  p.  42):  Orphan  in  Macon. 
Fort  Valley,  Houston  County,  1902 50  cases,  0  death. 

STILES  (1903b,  p.  42) :  Dr.  BROWN  stated  he  could  easily  find  50  or  more  cases.  We 
examined  about  10  cases  together. 

Jackson  County,  1902 ?  cases,  ?  deaths. 

Dr.  HARDMAN,  quoted  by  STILES  (1903b,  p.  41). 
Johnson  County,  1902  . .  1  case,  0  death. 

STILES  (1903b,  p.  42):  Orphan  in  Macon. 
Jones  County,  1902 4  cases,  0  death. 

STILES  (1903b,  p.  42):  Orphan  in  Macon. 
Kinderlou  Station,  Lowndes  County 1  case,  0  death. 

STILES  (1903b,  p.  42):  Orphan  in  Macon. 
Lee  County,  1902  _  _  _ .  -  4  cases,  0  death. 

STILES  (1903b,  p.  43):  Observed  with  Dr.  HILSMAN. 
Lyon,  Tattnall  County,  1902 ..  .-1  case.  0  death. 

STILES  (1903b,  p.  42):  Orphan  in  Macon. 

Macon,  Bibb  County,  1902. .  -.[29  cases,  0  death.] 

STILES  (1903b,  pp.  41-42):  At  orphan  asylums.  See  Americus  (1),  Baxley  (1), 
Buena  Vista  (1),  Cordele  (1),  Darien  (1),  Effingham  (1),  Johnson  (1),  Jones  (4), 
Kinderlou  (1),  Lyon  (1),' Monroe  (1),  Rich  wood  (2),  Sandersville  (1),  Thomas- 
ville  (1),  Savannah  (1),  Waycross  (3),  Monroe  (1),  Georgia.  Also:  Deland  (4), 
Liveoak  (1),  Wacissa  (1),  Florida. 

Macon,  Bibb  County,  1902  .  _ . about  25  to  30  cases,  0  death. 

STILES  (1903b,  p.  42):  About  25  to  30"  cases;  men,  women,  and  children  in  the 
cotton-mill  families. 

Monroe  County,  1902 ______        1  case,  0  death. 

STILES  (1903b,  p.  42):  Orphan  in  Macon. 

Richwood,  Dooly  County,  1902 2  cases,  0  death. 

STILES  (1903b,  p.  42):  Orphan  in  Macon. 

Sandersville,  Washington  County,  1902 1  case,  0  death. 

STILES  (1903b,  p.  42) :  Orphan  in  Macon. 


105 

Savannah,  Chatham  County,  1902  .  ..1  case,  0  death. 

STILES  (1903b,  p.  42):  Orphan  in  Macon. 
Thomas ville,  Thomas  County,  1902__.    -..I- case,  0  death. 

STILES  (1903b,  p.  41):  Orphan  in  Macon. 
Washington  County,  1902  -  .  -  ?  cases,  0  death. 

In  personal  conversation  with  Dr.  A.  MOODY  BURT,  I  was  informed  that  there  were 
a  number  of  persons  in  Washington  County  who  show  in  general  the  symptoms  of 
uncinariasis. 

Waycross,  Ware  County,  1902 -3  cases,  0  death. 

STILES  (1903b,  p.  42):  Orphan  in  Macon. 
Waycross,  Ware  County,  1902_-._. _  .  .-.I  cases,  ?  deaths. 

STILES  (1903b,  p.  43):  Many  cases,  number  not  estimated ;  about  20  cases  of  uncina- 
riasis to  1  of  malaria;  on  authority  of  Drs.  IZLAR  and  WALKER. 

Willacoochee  and  vicinity,  Coffee  County,  1902.  .200  cases,  0  death. 

STILES  (1903b,  p.  43):  Given  on  authority  of  Dr.  WILCOX.  We  examined  8  cases 
together. 

FLORIDA. 

Judging  from  the  size  of  the  eggs  all  the  cases  I  found  in  Florida, 
so  far  as  examined  microscopically,  were  due  to  Uncinaria  americana. 

Prior  to  1845 ?  cases,  ?  deaths. 

LITTLE  (1845)  refers  to  dirt-eating;  see  STILES  (1902b,  p.  208). 
Locality  ?,  1902 -  - ?  cases,  ?  deaths. 

GUITERAS'S  cases;  see  STILES  (1902b,  p.  215). 
Locality  ?,  1902 -  -  -1  case,  0  death. 

HARRIS  (1902c,  p.  776) :  Locality  not  given;  originated  in  Florida. 
Baker  County  . . . ?  cases,  ?  deaths. 

In  personal  conversation  with  a  Jacksonville  druggist,  I  was  informed  that  so-called 
dirt-eaters  are  common  in  Baker  County. 

Clay  County ?  cases,  ?  deaths. 

In  personal  conversation  with  a  Jacksonville  druggist,  I  was  informed  that  so-called 
dirt-eaters  are  common  in  Clay  County. 

Deland,  Volusia  County,  1902. _  -.4  cases,  0  death. 

STILES  (1903b,  p.  42):  Orphans  in  Macon,  Ga. 
Jacksonville,  Duval  County,  1902 2  cases,  Okdeath. 

STILES  (1903b,  p.  44). 
Li veoak,  Suwanee  County,  1 902 - 1  case,  0  death. 

STILES  (1903b,  p.  42):  Orphan  in  Macon,  Ga. 
Tampa,  Hillsboro  County,  1903  _ .  _  -  -  -  -12  cases,  0  death. 

In  a  letter  dated  March  21,  1903,  Dr.  J.  S.  HELMS  says:  "I  have  to  date  collected 
12  cases  and  am  yet  working.  I  dare  say  that  there  are  hundreds  of  cases  in  south 
Florida."  The  parasites  were  Uncinaria  americana. 


106 

Wacissa,  Jefferson  County,  1902 . .          1  case,  0  death. 

STILES  (1903b,  p.  42):  Orphan  in  Macon,  Ga. 

Ocala,  Marion  County,  1902 5  cases,  0  death. 

STILES  (1903b,  p.  44). 

Twiggs  County,  1902 '. ?  cases,  U  deaths. 

I  have  been  informed  that  in  Twiggs  County  there  exists  a  condition  which  cor- 
responds to,  uncinariasis. 

Upson  County .  _  ?  cases,  ?  deaths. 

There  is  said  to  exist  a  great  deal  of  ' '  bloat ' '  in  this  county.  Possibly  this  ' '  bloat ' ' 
is  due,  in  part  at  least,  to  uncinariasis. 

Waldo,  Alachua  County,  1902. . . about  12  cases,  0  death. 

STILES  (1903b,  p.  44). 

ALABAMA. 

?  Locality. . .          ?  cases,  ?  deaths. 

LYELL,  quoted  by  BLANCHARD,  1888a.     Could  not  be  traced. 

Middle  Alabama,  1902 _  _  1  case,  0  death. 

HARRIS  (1902c,  p.  776). 
Mobile  and  vicinity 24  cases,  0  death. 

The  following  extracts  are  made  from  a  letter  dated  March  3,  1903,  from  DR.  E.  D. 
BONDURANT,  professor  of  pathology,  medical  department,  University  of  Alabama: 
"Some  weeks  ago  a  fellow  practitioner  told  of  cases  of  intense  and  protracted  anemia 
he  was  treating,  suggested  the  possibility  of  uncinariasb,  and  asked  me  to  make  a 
microscopic  examination  of  the  fecal  discharges.  This  was  done,  and  I  had  no 
difficulty  in  promptly  identifying  the  hookworm  ova  in  the  feces  of  every  one  of  his 
4  cases.  Shortly  afterward  I  came  upon  2  cases  in  my  own  practice,  found  the  ova  in 
quantity,  and  after  thymol  I  found  numbers  of  adult  worms.  At  the  city  hospital 
we  have  already  had  several  [?3]  others,  and  one  physician  who  has  actively  taken 
up  the  search  in  his  anemic  'country  patients  tells  me  that  he  has  found  about  15 
cases.  There  is  no  doubt  that  the  disease  is  very  common  in  the  country  surround- 
ing Mobile.  *  *  *  Our  'poor  whites'  are  surely  widely  infected  with  the 
disorder  *  *  *  ." 

In  a  letter  dated  March  13,  Dr.  E.  D.  Bondurant  says:  "I  have,  since  1  last  wrote 
you,  diagnosed  cases  from  Monroe  County,  Covington  County,  and  Crenshaw  County, 
this  State,  as  well  as  numerous  other  cases  in  the  district  immediately  around 
Mobile.  *  *  *  All  of  my  cases  have  promptly  improved  after  thymol." 

Monroe  County,  1903 1  case,  0  death. 

Quoted  on  the  authority  of  a  letter  dated  March  3,  1903,  from  DR.  E.  D.  BON- 
DURANT. 

Waldo,  Talladega  County ?  cases,  ?  deaths. 

A  trained  nurse,  Miss  Edith  Lide,  has  described  to  me  a  family  at  Waldo  whose 
symptoms  (anemia,  heart,  emaciation,  dirt-eating,  etc.)  point  almost  unmistakably 
to  hookworm  disease. 

MISSISSIPPI. 

One  of  the  American  physicians  (Dr.  Kirby-Srnith)  who  saw  several 
cases  of  uncinariasis  in  Cuba  has  recently  stated  to  me  that  this  disease 
is  undoubtedly  present  in  Mississippi,  but  its  exact  nature  has  not  been 
recognized.  He  is  convinced  that  he  himself  has  seen  a  number  of 
cases  which  were  confused  with  malaria. 


107 

ARKANSAS. 

Uncinariasis  does  not  appear  to  be  proved  as  yet  for  Arkansas,  but 
I  have  been  told  that  it  is  probably  present. 

LOUISIANA. 

Louisiana,  prior  to  1821  and  1850 .  _  _  1 ?  cases,  ?  deaths. 

[    CHABERT'S  (1821a)  and  DUNCAN'S  (1850,  St.  Mary  Parish)  accounts  of  dirt-eating 
apply  very  well  to  uncinariasis.     See  STILES  (1902b,  p.  207) . 

New  Orleans,  1899 _• .1  case,  0  death. 

TEBAULT'S  (1899)  case.     See  STILES  (1902b,  p.  209). 

Dirt-eaters  are  said  to  be  numerous  in  the  Mississippi  Delta  near  Baton  Rouge. 

TEXAS. 

Locality?,  1864 1  case,  1  death. 

HERFF'S  (1864)  case  in  Mexican  woman.     See  STILES  (1902b,  p.  208). 

Galveston,  1894 1  case,  0  death. 

ALLEN  J.  SMITH'S  case,  reported  by  SCHAEFER  (1901).     See  STILES  (1902b,  p.  208). 

Galveston,  1900-1901 . .  .1  case,  0  death. 

;    SCHAEFER' s  (1901)  case;  probably  infected  in  Mexico.     See  STILES  (1902b,  p.  211). 

Galveston,  1901 8  cases,  0  death. 

ALLEN  J.  SMITH'S  cases,  reported  in  part  by  SCHAEFER  (1901).  See  STILES  (1902b, 
p.  211) .  At  least  one  of  these  cases  was  due  to  Uncinaria  americana. 

Encinal,  La  Salle  County;  Heampstead,  Waller  County;  Lavaca 

County,  1898 ?  cases,  ?  deaths. 

Upon  seeing  my  description  of  hookworm  disease  and  the  photograph  from  which 
figure  42  was  made,  MR.  CHARLES  A.  PFENDER,  assistant  in  the  Zoological  Laboratory, 
IT.  S.  Bureau  of  Animal  Industry,  stated  to  me  that  he  had  seen  similar  conditions 
among  Mexican  children  in  Encinal,  among  negroes  at  Heampstead  in  Brazos  River 
bottom,  and  among  the  poorer  people  in  the  southern  portion  of  Lavaca  County, 
along  the  Navidad  River. 

CENTRAL  STATES, 

ILLINOIS. 
Chicago,  1902 1  case,  1  death. 

CAPPS  (1902a;  1903a,  pp.  28-33) :  Patient,  G.  L.,  in  Cook  County  Hospital;  male;  52 
years  old;  carpenter;  American.  Infection  probably  took  place  at  Panama.  Earliest 
symptoms  two  years  ago,  aching  pain  in  upper  belly,  loss  of  appetite,  and  weakness. 
No  nausea  or  vomiting.  Bowels  irregular,  loose  or  constipated.  Later,  shortness  of 
breath  and  dizziness;  also  palpitation  of  heart.  In  hospital  fifteen  months  at  New 
Orleans;  diagnosis,  pernicious  anemia.  September  9, 1902,  admitted  to  Cook  County 
Hospital;  pains  in  belly,  weakness,  dyspnea,  and  palpitation.  After  sitting  or 
standing  feet  would  swell.  Frequent  dizziness  and  faintness.  Occasionally  had 
developed  moderate  fever,  at  which  time  epigastric  pain  was  worse.  Appetite  poor. 
Constipation.  Gradual,  moderate  emaciation. 

"Status  presens. — Man  of  medium  build;  skin  of  a  lemon-yellow  color.  Fatty 
layer  fairly  well  preserved.  Sclerotics  bluish  and  muddy.  Lips  and  mucous  mem- 
branes almost  bloodless.  Palpable  arteries  moderately  thickened.  Pulse  of  large 
volume,  soft  and  compressible;  low  tension,  with  a  decided  water-hammer  character. 
Lungs  negative.  Heart  dullness  extended  to  the  left  nipple  line,  to  the  upper  border 
of  the  third  rib  above,  and  to  the  right  edge  of  the  sternum.  The  impulse  was  forci- 
ble and  diffuse.  Over  the  apex  was  a  systolic  blow  transmitted  to  the  anterior  axil- 


108 

lary  line.  A  louder  bruit  of  a  different  pitch  was  audible  over  the  mitral  area  and 
the  base.  The  pulmonic  sound  was  louder  than  the  aortic  closure. 

"  The  spleen  was  not  palpable,  though  its  area  of  dullness  was  enlarged.  The  liver 
was  not  felt.  T*he  epigastric  and  umbilical  regions  were  tender  to  pressure.  Knee 
jerks  present  but  not  prompt. 

''Temperature  98.6,  pulse  90,  respiration  20.  Urine  1.015;  no  albumen,  no  sugar, 
and  no  casts. 

11  September  11,  blood  examination  showed  hemaglobin  18  per  cent;  reds,  2,576,000; 
whites,  6,600.  No  stained  preparations  were  made. 

"  September  15,  gastric  contents  were  expressed  one  hour  after  a  test  meal  of  tea 
and  toast.  No  free  HC1  present;  no  lactic  acid. 

"September  23,  blood  examination,  hemog.  17  per  cent;  reds,  2,280,000;  whites, 
6,000. 

"October  20,  blood  examination,  hemog.  12.5  per  cent;  reds,  843,000;  hematocrit, 
980,000;  whites,  4,500;  color  index,  0.80;  volume  index,  1.17.  The  differential  count 
showed:  small  mononuclear,  10  per  cent;  large  mononuclear,  11  per  cent;  polymorph. 
neutrophile,  66  per  cent;  polymorph.  eosinophiles,  13  per  cent;  no  rouleaux  forma- 
tion; no  nucleated  red  cells;  poikilocytosis  marked;  polychromatophilia  marked. 

''The  presence  of  pronounced  eosinophilia  in  a  case  of  grave  anemia  made  us 
strongly  suspect  the  existence  of  an  intestinal  parasite,  so  that  the  stools  were  exam- 
ined frequently.  The  earlier  specimens  of  feces  were  watery  from  the  rectal  injections 
employed,  and  were  therefore  not  easily  studied.  In  a  formed  movement,  however, 
the  ova  were  found  in  large  numbers.  These  eggs  corre -ponded  accurately  in  dimen- 
sions to  those  of  Uncinaria  duodenalis,  measuring  about  56  microns  in  length  and  34 
microns  in  width. 

"  Subsequently  the  eggs  of  Tricocephalus  dispar  were  found  in  small  number  by 
Dr.  J.  L.  Miller.  Charcot-Leyden  crystals  were  present  in  some  preparations,  absent 
in  others.  Cover  glass  smears  of  feces  hardened  in  alcohol  and  ether  were  stained 
with  hematoxylin  and  eosin  and  eosinophilic  granulations  demonstrated.  These 
granulations,  like  the  Charcot  crystals,  were  never  numerous,  as  is  so  often  the  case 
in  ankylostomiasis. 

"  The  eggs  were  successfully  cultivated  and  the  larva?  brought  to  mature  develop- 
ment. These  experiments  will  be  described  later. 

"November  6,  examination  of  the  blood  gave:  hemaglobin  11  per  cent;  reds, 
748,000;  hematocrit,  915,000;  wrhites,  5,600;  color  index,  88  per  cent;  volume  index, 
122  per  cent.  Differential  count:  small  mononuclear,  15.8  per  cent;  large  mono- 
nuclear,  6.8  per  cent;  polymorph.  neutrophile,  70.2  per  cent;  eosinophile,  7.6  per 
cent;  eosinophilic  myelocytes,  0.2  percent;  mast  cells,  0.4  per  cent.  Poikilocytosis 
and  polychromatophilia  marked.  Coagulation  time,  five  minutes. 

"Previous  to  this  examination  the  patient  had  taken  thymol  in  small  doses,  and 
it  is  not  unlikely  that  many  parasites  were  swept  away  and  lost  in  the  stools.  The 
diminished  eosinophilia  and  the  small  number  of  eggs  found  in  the  stools  thereafter 
lend  support  to  this  assumption. 

"History  in  the  hospital — Treatment,  on  the  whole,  was  unsatisfactory,  because  of 
the  profound  weakness  of  the  patient  and  the  irritable  condition  of  the  stomach.  A 
persistent  nausea  set  in  that  interfered  with  stomach  feeding  and  made  the  adminis- 
tration of  thymol  ineffective  and  even  hazardous.  Nutrient  and  salt  enemata  were 
resorted  to,  but  the  vomiting  persisted  until  the  patient  succumbed,  on  November  13. 

"During  his  stay  in  the  hospital  the  most  conspicuous  symptom  was  epigastric  pain 
of  a  dull  nature  at  first,  subsequently  colicky.  In  the  last  two  weeks  this  pain 
became  continuous,  and  was  accompanied  by  a  great  tenderness  over  the  epigastric 
and  right  hypochondriac  regions.  The  liver  mass  extended  at  this  time  about  2 
inches  below  the  ,costal  arch,  and  the  tenderness,  on  pressure,  was  as  great  as  that 
seen  in  hepatic  abscess. 

"The  bowels,  as  a  rule,  were  constipated,  and  required  rectal  enemata.     The  tem- 


109 

perature  was  usually  normal,  and  ranged  between  98.5°  and  99.5°  F.  A  tendency  to 
hemorrhage  was  nowhere  to  be  seen,  except  from  the  intestinal  tract.  The  feces 
gave  the  prussian-blue  reaction  for  iron. 

"The  examination  of  the  eye  grounds  was  twice  carried  out  under  difficulties. 
No  retinal  hemorrhage  was  apparent. 

''The  blood  findings  throughout  were  of  a  most  suggestive  nature;  an  anemia, 
at  first  of  the  secondary  type,  progressing  until  it  corresponded  in  most  respects  to  a 
primary  pernicious  anemia.  The  individual  corpuscles  grew  .larger  and  held  an 
ever-increasing  amount  of  hemoglobin,  the  color  index  rising  from  38  to  88  per  cent, 
and  the  volume  index  reaching  122  per  cent.  The  poikilocytosis  was  sufficiently 
outspoken,  as  well  as  the  polychromatophilia,  for  a  primary  anemia.  The  scarcity 
of  nucleated  red  corpuscles  and  the  entire  absence  of  megaloblasts  is  unusual  in 
the  primary  pernicious  form,  yet  some  such  cases  have  been  reported.  What 
convinced  us  that  the  anemia  was  not  of  the  usual  primary  type  was  the  eosinophilia 
of  13  per  cent,  for  in  the  primary  disease  the  eosinophiles  are  rarely  increased.  On 
the  other  hand,  the  Uncinariae  and  most  of  the  other  intestinal  parasites  are  char- 
acterized by  an  increase  in  the  eosinophilic  cells. 

"Autopsy. — The  post-mortem  examination  was  made  November  13  by  Dr.  Harris, 
resident  pathologist  of  the  hospital.  His  report  is  as  follows: 

"Body  is  that  of  a  fairly  well-developed  and  fairly  well-nourished  man  162cm. 
tall.  Post-mortem  rigidity  and  lividity  present. 

"There  is  a  scar  0.5  cm.  long  on  left  arm,  some  edema  of  lower  extremities. 
Paniculus  adiposus  well  preserved  and  of  a  light-yellow  color. 

"  Abdominal  cavity:  Diaphragm  reaches  to  the  fifth  rib  on  the  right  side  and  to  the 
sixth  rib  on  the  left.  Some  free  straw-colored  fluid  in  peritoneal  cavity.  Omentum 
extends  down  to  the  pelvis  over  the  intestines  and  contains  a  considerable  quantity 
of  fat. 

"Pleural  cavities:  Some  firm  fibrous  adhesions  at  right  apex.  About  1,000  c.  c. 
straw-colored  fluid  in  right  pleural  cavity;  about  250  c.  c.  in  left.  Lungs  do  not 
meet  in  median  line. 

"Pericardial  cavity:  About  500  c.  c.  of  straw-colored  fluid  in  the. pericardial  cavity. 
This  fluid  contains  a  few  fibrinous  flocculi.  The  pericardium  is  thin  and  surface  is 
smooth. 

"Tongue,  pharynx,  larynx,  not  examined.  Thymus  absent.  Esophagus  and 
trachea  negative. 

"Lungs:  Left  lung  smooth  externally,  marginal  emphysema,  crepitates  through- 
out, floats  in  water,  cut  surface  smooth,  pale,  and  drips  fluid.  On  the  diaphragmatic 
surface  is  a  caseated  nodule  8  mm.  in  diameter.  Right  lung  with  the  exception  of 
the  caseous  nodule  corresponds  to  the  description  of  the  left.  Both  lungs  are  quite 
free  of  pigment  and  weigh  2,870  grams.  Peribronchial  lymph  glands  are  negative 
except  for  anthracosis. 

"Heart:  Cavities  are  quite  empty,  left  ventricle  contracted;  aortic  and  pulmonary 
semilunar  valves  are  competent,  read  by  water  test.  Some  fibrous  thickening  at  the 
base  of  the  aortic  valves.  One  of  the  valves  has  small  fenestration  3  mm.  long. 
Pulmonary  valves  show  no  change.  The  mitral  orifice  admits  three  fingers,  and  the 
valve  shows  a  small  amount  of  fibrous  thickening,  especially  near  the  free  borders. 
The  tricuspid  orifice  admits  five  fingers;  the  valves  show  no  changes.  The  left 
ventricle  has  an  aberrant  corda  tendina  extending  from  the  septum  to  the  left  wall. 
Ventricular  wall  measures  16  mm. ;  right  ventricular  wall  measures  5  mm.  Heart 
muscle  is  firm  and  very  yellow,  but  not  mottled.  Heart  weight,  300  grams.  There  is 
a  slight  increase  of  the  subepicardial  fat.  There  are  a  few  atheromatous  patches  in 
the  ascending  aorta. 

"Spleen:  About  one-half  larger  than  normal;  capsule  is  smooth,  parenchyma  is 
quite  firm;  malphigian  bodies  prominent;  there  is  an  evident  increase  of  connective 
tissue.  The  organ  wreighs  225  grams. 


110 

"Kidneys:  Eight  weighs  175  grams.  Section  pale,  cortical  markings  not  well 
seen;  relation  between  cortex  and  medulla  is  normal;  capsule  strips  readily;  pelvis 
is  normal.  Left  kidney  weighs  135  grams.  Answers  to  the  description  of  its  fellow. 

"Ureters,  bladder,  testicles,  and  adrenals  present  no  abnormal  appearances. 

' '  Liver :  Extends  4  cm .  below  costal  arch ;  capsule  smooth  and  glistening — presents 
yellowish  mottled  appearance.  Cut  surface  mottled  yellow  and  red,  lobules  well 
seen.  Liver  cuts  with  decreased  resistance.  Weighs  1,600  grams.  Bile  ducts  pat- 
ent, bile  dark  brown,  no  concretions.  Pancreas  shows  no  changes. 

"Stomach:  Of  normal  size,  externally  is  normal;  mucosa  is  covered  with  much 
grayish-yellow  mucus;  no  parasites. 

"  Small  intestines:  External  appearance  normal.  Intestines  contain  a  very  large 
amount  of  very  tenacious  mucus.  In  the  duodenum  was  found  one  hook  worm. 
One  hundred  and  fifty  wrere  found  in  the  jejunum  and  upper  part  of  ileum,  being 
most  numerous  in  the  upper  and  middle  jejunum.  None  found  in  last  18  inches  of 
ileum.  They  were  very  adherent,  and  were  in  the  proportion  of  about  four  females 
to  one  male.  At  point  of  attachment  of  some  of  the  parasites  was  found  a  small 
ecchymotic  spot,  and  scattered  along  the  rest  of  the  mucosa  a  few  other  ecchymotic 
spots  were  seen — possibly  points  of  previous  attachment.  The  mucus  in  places  was 
blood-stained.  Mesenteric  glands  were  enlarged  and  of  a  pinkish  color.  Appendix 
lies  in  false  pelvis  to  the  outside  of  psoas  muscle  and  behind  cecuin — bound  down 
by  fibrous  adhesions  and  curled  at  its  tip. 

' '  Spinal  cord  shows  no  microscopic  changes. 

"Bone  marrow  removed  from  femur.  Marrow  is  yellow  and  very  fatty.  At  two 
points  it  had  a  reddish  color,  but  was  even  here  practically  all  fat. 

"  Anatomic  diagnosis:  I.  Uncinaria  duodenalis  of  small  intestine.  2.  Ecchymosisof 
intestinal  mucosa,  and  hemorrhage  into  intestinal  lumen.  3.  General  anemia  and 
edema  of  dependent  portions  of  body.  4.  Bilateral  hydrothorax.  5.  Hydroperi- 
cardium.  6.  Edema  of  lungs  and  caseous  tuberculosis  of  lower  left  lobe.  7.  Slight 
atheroma  of  aorta.  8.  Fatty  degeneration  of  heart  and  liver.  9.  Aberrant  corda 
tendina.  10.  Passive  congestion  and  fatty  degeneration  of  liver.  11.  Chronic  inter- 
stitial splenitis." 

WESTEKN  STATES. 

MISSOURI. 
St.  Louis,  1893 1  case,  0  death. 

BLICKHAHN'S  (1893a)  case;  probably  imported  from  Germany  and  caused  by  Agchy- 
lostoma  duodenale.  See  STILES  (1902b,  p.  208). 

St.  Louis,  1901_.  ..1  case,  0  death. 

DYER'S  (1901)  case.     See  STILES  (1902b,  p.  213). 

CALIFORNIA. 

San  Francisco,  1902  ..'.  2  cases,  0  death. 

Letters  from  Drs.  G.  H.  EVANS  and  MARY  HALTON,  1902:  Two  soldiers  who  returned 
from  the  Philippines.  Through  the  kindness  of  the  observers  I  was  able  to  exam- 
ine specimens  from  one  of  these  cases,  and  to  convince  myself  that  they  belonged 
to  the  American  species.  The  previous  history  of  the  patient  was  not  obtained. 

San  Francisco,  1903 2  cases,  0  death. 

BROWN  (1903,  p.  107):  Three  patients  infected  with  Strong yloides;  2  of  these  (natives 
of  Porto  Rico)  were  also  infected  with  Uncinaria. 

?  Locality  . ..  .  .3  cases,  0  death. 

L.  MIFFITT'S  (cases  cited  by  CAPPS,  1903a).  Two  cases  from  Mexico,  one  from  the 
Philippines.  Diagnosis  by  ova. 


Ill 

BIBLIOGRAPHY. 

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1902  a. — Ankylostomiasis  in  an  individual  presenting  all  of  the  typical  symptoms  of 

pellagra  <Am.  Med.,  Phila.,  v.  4  (3),  July  19,  pp.  99-100.     [Wa,  Wm.] 
1902  b. — A  case  of  ankylostomiasis  presenting  the  symptoms  of  pellagra.     [Prac- 
tically same  as  Harris,  1902  a]  <Tr.  M.  Ass.  Georgia,  Atlanta,  53.  Session, 
pp.  220-227.     [Discussion,  pp.  232-236.]     [Wm.] 

1902  c. — Ankylostomiasis,  the  most  common  of  the  serious  diseases  of  the  southern 
part  of  the  United  States  <Am.  Med.,  Phila.,  v.  4  (20),  Nov.  15,  p.  776. 
[Wa,  Wm.] 
HEMMETER,  JOHN  C. 

1902. — Diseases  of  the  intestines,  their  special  pathology,  diagnosis,  and  treatment 
with  sections  on  anatomy  and  physiology,  microscopic  and  chemic  exam- 
ination of  the  intestinal  contents,  secretions,  feces,  and  urine.  Intestinal 
bacteria  and  parasites;  surgery  of  the  intestines;  dietetics,  diseases  of  the 
rectum,  etc.  v.  2,  679  pp.,  65  figs.,  13  pis.  8°.  Philadelphia.  [Wm.] 
HERFF,  F. 

1894. — Report  of  parasitic  entozoa  encountered  in  general  practice  in  Texas  during 
over  forty  years  <Texas  M.  J.,  Austin,  v.  9  (12),  June,  pp.  613-616. 
[W»] 

HERRTCK,  A.  B. 
1902. — A  case  of  severe  anemia  caused  by  the  Uncinaria  duodenalis  <Am.  Med., 

Phila.,  v.  4  (3),  July  19,  p.  101.     [Wa,  Wm.] 
IMRAY,  JOHN. 

1843. — Observations  on  the  mal  d'estomac,  or  cachexia  africana,  as  it  takes  place 
among  the  negroes  of  Dominica  <^E^inb.  M.  &  S.  J.,  v.  59,  Apr.  1,  pp. 
304-321.     [Wra.] 
JOACHIM,  H. 

1890. — Papyros  Ebers.     Das  iilteste  Buch  iiber  Heilkunde.    Aus  dem  Aegyptischen 
zurn  erstenmal  vollstiiiidig   iibersetzt.      xx-f214-f-l   pp.     8°.      Berlin. 
[W-.] 
JORDAN,  C.  H. 

1832. — Thoughts  on  cachexia  africana,  or  negro  consumption  <^Transylv.  J.  M., 

Lexington,  Ky.,  v.  5  (1),  Jan.-Mar.,  pp.  18-30.     [Wm.] 
JORDAN,  DAVID  STARR;  &  CLARK,  GEORGE  ARCHIBALD. 

1898. — The  history,  condition,  and  needs  of  the  herd  of  fur  seals  resorting  to  the 
Pribilof  Islands.  (In  The  fur  seals  and  fur  seal  islands  of  the  North 
Pacific  Ocean,  by  David  Starr  Jordan  [&  others].  Pt.  1,  248+1+vii  pp., 
39illus.  4°.  Washington.  [Ws.] 

19558— No.  10—03 8 


114 

LE  CONTE,  JOHN.  ' 

1845. — Observations  on  geophagy  <South.  M.  &  S.  J.,   Augusta,  n.  s.,  v.  1  (8), 

Aug.,  pp.  417-444.     [MS.  dated  June  25.]     [Wm.] 
LEPINE,  R.     [Prof.  Faculte  de  meU,  Lyon.] 

1891a. — Sur  la  toxicite  de  1'extrait  de  fougere  mftle  <Semaine  med.,  Par.,  v.  11 

(41),  15aout,  p.  337.     [Wm.] 
1891b. — Sur  1' intoxication  produite  par  de  fortes  doses  d'extrait  de  fougere  male. — 

Action  oontraire  de  1'ergotine  <Semaine  med.,  Par.,  v.  11  (57),  25  nov., 

p.  465.     [Wm.] 
LEUCKART,  RUDOLF. 

1867. — Die  menschlichen  Parasiten  und  die  von  ihnen  herriihrenden  Krankheiten. 

v.  2,  1.  Lief.,  pp.  1-256,  figs.  1-158.     8°.     Leipzig  &  Heidelberg.     [Wa.] 
1868.— Idem  [continued],     v.  2,  2.  Lief.,  pp.  257-512,  figs.  159-282.     8°.     Leipzig 

&  Heidelberg.     [Wa.] 
1880. — Die  Parasiten  des  Menschen  und  die  von  ihnen  herriihrenden  Krankheiten. 

2.  Aufl.,  v.  1,  2.  Lief.,  pp.  i-xxii+337-856,  figs.  131-353.     8°.     Leipzig  & 

Heidelberg.     [Wa.] 
1889.— Idem    [continued].,    2.   Aufl.,    v.    17  2.    Abt,,    4.    Lief.,    pp.    97-440.     8°. 

Leipzig. 
LITTLE,  ROBERT  EDMONDS. 

1845. — Remarks  on  the  climate,  diseases,  etc.,  of  middle  Florida,  particularly  of  Gads- 
den  County  <Am.  J.M.Sc.,  Phila.,n.s.,v.lO(19),  July,  pp.  65-74.   [Wm.] 
Looss,  ARTHUR. 

1896. — Recherches  sur  la  faune  parasitaire  de  FEgypte.     Premiere  partie  <Mem. 

de  Flnst.  e"gypt,,  Le  Caire,  v.  3,  pp.  1-252,  pis.  1-16.     [Lib  Stiles.] 
1897. — Notizen  zur  Helminthologie  Egyptens.   II  <Centralbl.  f.  Bakteriol.,  Parasit- 

enk.  [etc.],  Jena,  1.  Abt.,  v.  21  (24-25),  10.  Juli,  pp.  913-926,  figs.  1-10. 

[W.] 
1898. — Zur  Lebensgeschichte  des  Ankylostoma  duodenale.     Eine  Erwiderung  an 

Herrn  Prof.   Dr.   Leichtenstern  <Centralbl.    f.   Bakteriol.,   Parasitenk. 

[etc.],  Jena,  1.  Abt.,  v.  24  (12),  27.  Sept.,  pp.  441-449;   (13),  12.  Okt.,  pp. 

483-488.     [Wa,  Wm.] 
1901. — Ueber  das  Eindringen  der  Ankylostomalarven  in  die  menschliche  Haut 

<Centralbl.  f.  Bakteriol.,  Parasitenk.  [etc.],  Jena,  1.  Abt,,  v.  29  (18),  31. 

Mai,  pp.  733-739,  1  pi.,  figs.  1-3.    [Wa,  Wm.] 
1902. — Ueber  die  Giltigkeit  des  Gattungsnamens  Ankylostomum  Dubini  <Centralbl. 

f.  Bakteriol.,  Parasitenk.  [etc.],  Jena,  1.  Abt.,  v.  31  (9),  5.  Apr.,  Originale, 

pp.  422-425.     [Wn,  Wm.] 
1903. — Weiteres  liber  die  Einwanderung  der  Ankylostomen  von  der  Haut  aus 

<Centralbl.  f.  Bakteriol.,  Parasitenk.   [etc.],  Jena,  1.  Abt,,  v.  33  (5),  6. 

Feb.,  Originale,  pp.  330-343.     [MS.  dated  Dec.,  1902.]     [W%  W»] 
LUSSANA,  FELICE. 

1890. — Contribute  alia  patogenesi  dell'  anemia  da  anchilostomiasi  <Arch.  ital.  di 

clin.  med.,  Milano,  An.  29  (4),  31  die.,  pp.  759-776.     [Wm.] 

MCEHLAU,   F.   G. 

1897. — Anchylostamum  duodenale,  with  report  of  cases  <Buffalo  M.  J.,  v.  36  (8), 

Mar.,  pp.  573-579.     [Wm.] 
PERRONCITO,  EDOARDO. 

1882. — I  parassiti  dell'  uomo  e  degli  animali  utili,  delle  piu  comuni  malattie  da 

essi  prodotte,  profilassi  e  cura  relativa.     xii-f  506  pp.,  233  figs.,  14  pis. 

8°.     Milano.     [W%  \Vm.] 

PlSO,  GULIELMUS. 

1648. — De  medecina  Brasiliensi  libri  quatuor.  (Forms  first  part  of  his  Historia  natu- 
ralis  Brasilia*,  in  qua  non  tantum  plants  et  animalia,  sed  et  indigenarum 
morbi,  ingenia  et  mores  describuntur  et  iconibus  supra  quingentis  illus- 
trantur).  fol.  Lugd.  Bat.  84-122+2  pp.,  figs.)  [Wm.j 


115 

PITT,  JOSEPH. 

1808. — Observations  on  the  country  and  diseases  near  Roanoke  River,  in  the  State 
of  North  Carolina  <Med.  Reposit.,  N.  Y.,  2.  hexade,  v.  5  (4),  Feb. -Apr., 
pp.  337-342.  [Wn1.] 

PLASENCIA,  LEONEL. 

1902. — Estudio  comparative  sobre  el  Uncinaria  duodenal!*  \  americana  <Rev.  de 
med.  trop.,  Habana,  v.  3  (11),  nov.,  pp.   175-189,  rigs.  1-7,   pis.  1-4. 
[Wa,  Wm.] 
POLLARD,  THOMAS. 

1852. — More  than  150  gravel  taken  from  the  bowels  of  a  dirt-eating  child  <Stetho- 
scope  &  Virg.  M.  Gaz.,  Richmond,  v.  2  (4),  Apr.;  p.  185.  [Wm.] 

SAND  WITH,  F.  M. 

1894. — Observations  on  four  hundred  cases  of  anchylostomiasis.     Written  for  the 
Eleventh  International  Medical  Congress,  held  in  Rome,  1894.     27  pp. 
8°.     London.     [Wm.] 
1902. — Proof  that  Ankylostoma  larvae  can  enter  the  skin  <J.   Trop.   M.,   Lond., 

v.  5  (24),  Dec.  15,  pp.  380-381.     [Wm.] 
SCHAEFER,  M.  CHARLOTTE. 

IWl.—Anchylostoma  duodenale  in  Texas  <Med.  News,  N.  Y.,  v.  79  (17),  Oct.  26, 
pp.  655-658.  [Wa,W'».] 

SCHEUTHAUER,  GUSTAV. 

1881. — Beitriige  zur  Erkliirung  des  Papyrus  Ebers,  des  hermetischen  Buches  liber 
die  Arzneimittel  der  alten  Aegypter  <Arch.  f.  path.  Anat.  [etc.],  Berl., 
v.  85  (2),  8.  F.,  v.  5  (2),  8.  Aug.,  pp.  343-354.     [Wm.] 
SCHNEIDER,  ANTON. 

1866. — Monographic  der  Neniatoden.    vii+357  pp.,  130  figs.,  28  pis.    4°.    Berlin. 

[Wa.] 
SMITH,  CLAUDE  A. 

1902. — Report  of  a  case  of  ankylostomiasis.     [Secretary's  abstract  of  paper  pre- 
sented before  Section  on  Physiology  and  Pathology,  Am.   Med.   Ass., 
June  10-13]  <Am.  Med.,  Phila.,  v.  3  (25),  June  21,  p.  1062.     [W%  Wm.] 
STERNBERG,  GEO.  M. 

1900. — Report  of  the   Surgeon-General  of  the  Army  to   the  Secretary  of  War. 
411   pp.      8°.     Washington.      [pp.    274-277,    Ankylostomiasis;    contains 
Ashford,  1901.]"  [W1".] 
STILES,  CH.  WARDELL. 

1901. — Uncinariosis  (anchylostomiasis)  in  man  and  animals  in  the  United  States 

<Texas  M.  News,  Austin,  v.  10  (9),  July,  pp.  523-532.     [Wa,  Wm.] 
1902a. — A  new  species  of  hookworm  (  Uncinaria  americana)  parasitic  in  man  <Am. 

Med.,  Phila.,  v.  3  (19),  May  10,  pp.  777-778.     [Wa,  Wni.] 

1902b. — The  significance  of  the  recent  American  cases  of  hookworm  disease 
( uncinariasis,  or  anchylostomiasis)  in  man  <18th  Ann.  Rep.  Bureau 
Animal  Indust.,  U.  S.  Dept.  Agric.,  Wash.  (1901)  [issued  Sept.  25], 
pp.  183-219,  figs.  113-196.  [Wa.] 

1902c. — Hookworm  disease  in  the  South.  Frequency  of  infection  by  the  parasite 
(Uncinaria  americana)  in  rural  districts.  [Preliminary  report  to  the 
Surg.  Gen'l.  U.  S.  Pub.  Health  and  Marine-Hosp.  Serv.]  <Pub. 
Health  Rep.,  Wash.,  v.  17(43),  Oct.  24,  pp.  2433-2434.  [MS.  dated 
Oct.  22.]  [Wl,  Wn'.] 

1902d. — The  disinfection  of  kennels,  pens,  and  yards  by  fire  <Bull.  35,  Bureau 
Animal  Indust.,  U.  S.  Dept,  Agric.,  Wash.,  pp.  15-17,  pis.  1-2. 
[Wa,  Wm.] 

1903a. — Hookworm  disease  (uncinariasis) — a  newly  recognized  factor  in  American 
anemias.  [Abstract  of  address  delivered  before  Brooklyn  Med.  Soc., 
Jan.  17]  <Brooklyn,  M.  J.  (192),  v.  17  (2),  Feb.,  pp.  51-56.  [WV] 


116 

STILES,  CH.  WARDELL — Continued. 

1903b. — Report  upon  the  prevalence  and  geographic  distribution  of  hookworm  dis- 
ease ( uncinariasis  or  anchylostomiasis)  in  the  United  States  <Bull.  10, 
Hyg.  Lab.,  U.  S.  Pub.  Health  &  Mar-Hosp.  Serv.,  Wash.,  pp.  ,  1 
fig.  [W%W-.] 

STILES,  CH.  WARDELL;  &  HASSALL,  ALBERT. 

1902. — Index  catalogue  of  medical  and  veterinary  zoology.     Pt.  1  [Authors  A  to 
Azevedo.]  <Bull.   39,  Bureau  Animal.  Indust.,   U.   S.   Dept.   Agric., 
Wash.,  May  31,  pp.  1-46.     [Wa,  Wra.] 
1903.— Idem  [continued].     Pt,  2  [Authors  B  to  Buxton]  <Ibidem,  Feb.  16,  pp. 

47-198.     [Wa,  Wm.] 

STILES,  CH.  WARDELL;  &  PFENDER,  CHARLES  A. 

1902a. — The  failure  of  thymol  to  expel  whipworms  (Trichuris  depressiuscula)  from 
dogs  <J.  Comp.  M.  &  Vet.  Arch.,  Phila.,  v.  23  (12),  Dec.,  pp.  733-740. 
[WV3 
STRONG,  RICHARD  P. 

1901a. — Cases  of  infection  with  Strongyloides  intestinaUs  (first  reported  occurrence 
in  North  America)  < Johns  Hopkins  Hosp.  Rep.,  Bait,,  v.  10  (1-2), 
pp.  91-132,  pis.  2-3,  figs.  1-7.  [W%  Wm.] 

1901b. — Board  for  the  investigation  of  tropical  diseases  in  the  Philippines.     Cir- 
cular   No.  1.      Animal    parasites    <Rep.    Surg.-Gen.    Army,    Wash., 
pp.  203-219.     [Wa,  Wm.] 
TEBAULT,  C.  H.  (JR.). 

1899.— Anchylostomiasis  <N.  Orl.  M.  &  S.  J.,  v.  52  (3),  Sept.,  pp.  145-148.     [Wm.] 
THAYER,  WILLIAM  SYDNEY. 

1901. — On  the  occurrence  of  Strongyloides  intest'malis  in  the  United  States  <J.  Exper. 

M.,  Bait.,  v.  6  (1),  Nov.  29,  pp.  75-105,  pi.  9.     [Wa,  W'11.] 
THOMAS,  A.  P. 

1883. — The  natural  history  of  the  liver-fluke  and  the  prevention  of  rot  <J.  Roy. 
Agric.  Soc.  England,  Lond.,  2.  s.  (37),  v.  19   (1),  pp.  276-305,  figs.  1-20. 
[W«] 
VAN  DURME,  PAUL.     [Dr.,  Ghent.] 

1902. — Quelques  notes  sur  les  embryons  de  "Strongyloides  intestinalis"  et  leur  pene- 
tration par  la  peau  -^Thompson  Yates  Lab.  Rep.,  Liverpool,  v.  4,  pt,  2 
(32),  May,  pp.  471-474,  pi.  7,  figs.  1-4.     [Wa,  Wm.] 
WARD,  SAMUEL  B.     [M.  D.] 

-1903. — A  case  of  dysentery  due  to  double  infection  with  the  Uncinaria  duodenalis 
and  the  Amoeba  coll  < Albany  M.  Ann.,  v.  24  (1),  Jan.,  pp.  23-26.     [MS. 
dated  June  2, 1902.]     [Report  on  Dr.  R.  W.  A.'s  stools,  note  on  the  above 
by  George  Blumer,  p.  26.]     [Wm.] 
YATES,  JOHN  L. 

1901. — Pathological  report  upon  a  fatal  case  of  enteritis  with  anemia  caused  by 
Uncinaria  duodenalis  <Johns  Hopkins  Hosp.  Bull.,  Bait.   (129),  v.  12, 
Dec.,  pp.  366-372.     [Wa,  WTra.] 
ZTNN,  W.;  &  JACOBY,  MARTIN. 

1896. — Ueber  das  regelmiissige  Vorkommen  von  Anchylostomum  duodenale  ohne 
secundiire  Anamie  bei  Negern,  nebst  weiteren  Beitriigen  zur  Fauna  des 
Negerdarmes.  <Berl.  klin.  Wchnschr.,  v.  33  (36),  7.  Sept.,  pp.  797-801. 
[W«.] 

1898.— Ankylostomum  duodenale.  Uber  seine  geographische  Verbreitung  und  seine 
Bedeutung  fiir  die  Pathologic.  53  pp.,  2  maps.  8°.  Leipzig.  [Wm.] 


INDEX  TO  ZOOLOGICAL  NAMES. 


Page. 
Agchylostoma 3, 11, 13, 14, 15, 16,  21, 36 

caninum 17, 103 

duodenale 3,  7, 9, 13, 15, 17, 18, 19, 21, 22, 23, 24,  26, 

27,  29,  31,  32,33,  34,  50,  52,  56,  59,  60, 61,  63,  89, 99, 110,  111,  112, 115 

Amoeba  coli . 116 

Anchilostoma 15 

duodenale 21 

A  nchylostamum 15, 92 

duodenale  . 21, 114 

Anchylostoma 15, 16,  72,  92 

duodenale 21 

Ancylostoma 15 

duodenal? 21 

Ancylostomum 15 

duodenale 21, 116 

duodenate 21 

Ankylostoma 15, 115 

'  duodenale 21, 114 

Ankylostomum 1 5, 114 

duodenale 116 

Ascaris  criniformis 12, 15 

lumbricoides .  12,  37,  38,  75,  82,  85 

B'dharzia 77 

Bunostomum 14 

phlebotomum 17 

Dicrocoelium  lanceatum 8,  84 

Dochmius 15 

anchylostomum 21 

duodenalis 21 

Docmius 15 

duodenalis 21 

Dohmius * 15 

Doomius 15 

Fasdola  hepatica 8,  84 

Hxmonchus  contortus 14, 17,  75 

Ostertagi 75 

Hymenolepis 42 

nana 8,41,42,85 

Meles  taxus 12 

Metastrongylus 14 

Monodonta 15 

117 


118  INDEX    TO    ZOOLOGICAL    NAMES. 

Page. 

Monodontus 14, 15, 19 

semicircularis 15 

(Esophagostoma  dentatum 7, 13 

Ollulanus 4 

Oxyuris  vermicularis 8,  57,  82,  85 

Rhabditw 24 

Rhizoglyphus  parasiticus 60 

Schistosoma 77 

hfemalobium 8,  84 

ticlerostoma 14 

duodenale 21 

Sclerostomintti 14 

Strongylidse 3, 1 2, 13, 14,  24 

Strongylinse 3, 14, 15 

Strongyloides 110,  111 

intestinalis 116 

stercoralis 8,  60, 69, 82 

Strongylus 13, 14 

contortus 14 

duodenalis 21 

quadridentatus 21' 

Syngamus 14 

Tsenia  saginata 8,  84 

soliuni 8,  84 

Trichuris  affinis 8,  82 

depressiuscula 116 

trichiura 8, 37, 41,  82,  85 

Trichocephalus  dispar 85 

Tricocephalus  dispar 108 

Unciaria 15 

Uncinaria 3, 11, 13, 14, 15, 16, 19, 21, 32,  34,  37, 41,  49, 54,  57,  85, 93, 100, 103, 110 

americana 3, 9, 13, 17, 18, 19,  20,  33, 34, 35,  38,  39,  40, 41, 42, 43, 48, 58, 

65,  75,  85,  88,  91, 96, 97, 98,  99, 100, 101, 102, 103, 105, 107,  111,  113, 115 

canina - 14, 17 

cernua 17, 34 

duodenalis 3,14,16,21,24,35,108,110,113,115,116 

Lucasi 17,34,48 

melis - 15 

radiata 17,  34,  75 

stenocephala 14, 15, 17, 19, 34 

trigonocephala 17,  34, 48,  75 

vulpis 15, 19 

Uncinariinae 

Unicinaria 15 

americana 19 

Vulpes  lagopus 17 

vulpes 12 


INDEX  TO  AUTHORITIES  CITED. 


Page. 

Allyn,  Herman  B 33, 99, 11 1 

Anderson,  John  F , 2, 100 

Arslan,  Ervant 68,  111 

Ashford,  Bailey  K 33,34,58,70,98,111 

Bailhache,  Preston  H 98 

Barringer,  Dr 101 

Bason, 31 

Behrend,M 33,99,111 

Bentley,  Charles  A 59,60,61,62,63,64,111 

Blanchard,  Kaphael 101, 102, 106,  111 

Blickhahn,  Walter  L .' 32,110,111 

Blumer,  George 98,  111 

Bondurant,  E.  D 106 

Boring,  J.  W 44 

Boston,  L.  Napoleon 33 

Brown,  M.  S : .  42, 104 

Brown,  Philip  King 69, 110,  111 

Burt,A.Moody 42,48,105 

Causey,  P.  P 38 

Capps,  Joseph  A 91,107,111 

Carrington,  Charles  V 37 

Chabert,  Jean  Louis - 32, 52, 107, 1 1 1 

Chevalier,  J.  Damien 31,  111 

Clark,  George  Archibald 39,113 

Clark,  M.  A 41,66 

Clay  tor,  Thomas  A 33, 91 , 99,  100, 1 12 

Corbett,J.W  .„ 39 

Cotting,J.R 32,52,76,102,112 

Cragin,F.W „• 67,76,112 

Dalgetty ,  A.  B 60,  62, 1 12 

Dawson, 73 

Dawson,  Charles  F 17 

Dawson,  John 40 

Dazille,  Jean  Barthelemy 31, 112 

De  Saussure,  Henry  W 41 , 102 

Dobson,  Edwin  F.  H 80,112 

Drewry,  F.D ' 38 

Dubini,  Angelo 13,  31, 92, 112 

Duncan,  James  B 32,52,107,112 

Dyer,J.H 33,110,112 

Ebers,  Professor , 31 

Edwards,  —     — -  -  -         31 

Eichhorst,  Hermann 89, 112 

Elliot  (of  Assam) 62,112 

Ely,  W.  W 98, 112 

Evans,  G.  H 110 

119 


120  INDEX    TO    AUTHORITIES    CITED. 

Page. 

Flexner,  Simon 2 

Francis,  Edward 2 

Frcelich,  Joseph  Aloysius 12, 112 

Garrison,  Philip  E 2,  37 

Geddings,  William  H 32, 101 

Giles,  Surgeon-Major 49, 54, 56,  72, 87, 92 

Goeze,  Johann  August  Ephraim 13,112 

Gould,  A.  N 98, 112 

Gray,  William  B '. 33, 100,  112 

Green,  J.  Mercier 41 

Greene,  Joseph  B 98, 113 

Gregory  (of  Kershaw) 39 

Guiteras,  John  [Juan] 34,  69, 105, 113 

Hall,  E.  Lee 99, 113 

Halton,  Mary 110 

Hancock,  J.' 76,113 

Hardman,  Lamartine  G 41, 104 

Harris,  H.  F 35, 36, 41,  79,  80, 96, 103, 105, 106, 109, 113 

Helms,  J.  S..... 105 

Hemmeter,  John  C , 99, 113 

Herff,  F 32, 107, 113 

Herrick,  A.  B 99, 113 

Heusinger,  -      - 32, 101 

Hilsman,  Parlarmon  L 43,  66, 104 

H  uger,  William  H 41,  58 

Imray,  John 52,  67,  76, 113 

Izlar,  A.  L 44 

Izlar,  R.  P 44, 105 

Jacoby,  Martin 31,  52, 68, 116 

Joachim,  H 31, 113 

Jordan,  C.  H 32,52,76,111,113 

Jordan,  David  Starr 39, 113 

Kauffmann  (of  Cairo,  Egypt) 91 

Kirby-Smith 96, 106 

Labat,  —      - 31 

Le  Conte,  John ! 32,  52,  75, 102, 114 

Lepine,R 89,114 

Lethermann, : 32 

Leuckart,  Rudolf 82,84,114 

Lide,  Edith 106 

Little,  Robert  Edmonds 32,  39, 114 

Looss,  Arthur 30,  50,  56,  60,  63,  64,  84, 114 

Lucas,  Frederick  A 17,  39, 48 

Lusanna,  Felice 68, 1 14 

Lute,-     - 56,68 

Lyell,-     — 32,102,106 

McClintic,  Thomas  B 2 

McHatton,  Henry 42,  48 

Miffits,L 110 

Miller,  J.  L 108 

Mcehlau,F.G 33,98,114 

Murray,  Arthur  L 2 

Neuman, 98 

Ohlmacher,  A.  P 69 


INDEX    TO    AUTHORITIES    CITED.  121 

Page. 

Osier,  William 51, 99 

Parker,  Herman  B 2 

Perroncito,  Edoardo 114 

Perry,  M.  L 42 

Pfender,  Charles  A 87,107 

Piso,  Gulielmus 31, 114 

Pitt,  Joseph 32,101,115 

Plasencia,  Leonel 115 

Pollard,  Thomas 76,100,115 

Powell,  Thomas 42 

Hansom,  Brayton  H 2,  85, 100,  111 

Rosenau,  Milton  J 1,2 

Salmon,  Daniel  Elmer 

Sandwith,  F.  M 30,31,45,46,49,50,53, 

54,  56, 57,  60,  66,  68,  72,  73,  74,  75,  76,  77,  78,  79,  80,  86,  87, 88,  89, 91, 115 

Simons,  Grange 41 

Schaefer,  M.  Charlotte 22,33,34,107,115 

Scheuthauer,  Gustav - 31, 115 

Schneider,  Anton 115 

Scott, 66 

Sedgwick,  William  T 2 

Seheult,-    — - 60 

Smith,  Allen  J 20,32,34,107 

Smith,  Claude  A 35,103,115 

Staton,LeeW 38 

Sternberg,  George  M 115 

Stevenson,  Earle  C 2,  37, 100 

Stiles,  Charles  Wardell 115 

Strong,  Richard  P 69, 91, 116 

Stuart,  Richard  H 100 

Stubbert,  James  Edward 66 

Tebault,C.H.  (jr.) 33,107,116 

Thayer,  William  Sydney 69,  83, 98 

Theobald,  Frederick  B . 88 

Thiess,  Capt.  Adolf 39 

Thomas,  A.  P. 84,116 

Urie,John  F 2 

Vaughan,  Victor  C 

Van  Durme,  Paul 60, 116 

Walker,  J.  L 44, 105 

Ward,  Samuel  B 98,111,116 

Walters,  M.H 2 

Welch,  William  H 2 

Wesbrook,  Frank  F 2 

White,  L.N 38 

Wilcox,  J.  D 44,105 

Wille,  Clarence  W 2 

Wilson,  Robert  (jr. ) 40 

Wyman,  Walter 2,11 

Yates,JohnL - 91,116 

Zinn,W 31,52,68,116 

O 
19558— No.  10—03 9 


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